Method and apparatus for establishing parameters for cardiac event detection

ABSTRACT

A pacemaker having a motion sensor is configured to select an atrial event sensing vector of a multi-axis motion sensor for sensing atrial systolic events from a motion signal produced by the motion sensor. In some examples, the pacemaker determines a maximum amplitude during a sensing window for each one of multiple vector signals produced by the multi-axis motion sensor. The pacemaker may select the atrial event sensing vector signal from among the vector signals based on the determined maximum amplitudes.

REFERENCE TO RELATED APPLICATIONS

This application claims the benefit of U.S. Patent Application No.62/776,034, filed provisionally on Dec. 6, 2018, and U.S. PatentApplication No. 62/776,027, filed provisionally on Dec. 6, 2018, both ofwhich are incorporated herein by reference in their entirety.

TECHNICAL FIELD

This disclosure relates to a medical device and method for establishingparameters for detecting cardiac events from a motion sensor signal.

BACKGROUND

Implantable cardiac pacemakers are often placed in a subcutaneous pocketand coupled to one or more transvenous medical electrical leads carryingpacing and sensing electrodes positioned in the heart. A cardiacpacemaker implanted subcutaneously may be a single chamber pacemakercoupled to one transvenous medical lead for positioning electrodes inone heart chamber, atrial or ventricular, or a dual chamber pacemakercoupled to two intracardiac leads for positioning electrodes in both anatrial and a ventricular chamber. Multi-chamber pacemakers are alsoavailable that may be coupled to three leads, for example, forpositioning electrodes for pacing and sensing in one atrial chamber andboth the right and left ventricles.

Intracardiac pacemakers have recently been introduced that areimplantable within a ventricular chamber of a patient's heart fordelivering ventricular pacing pulses. Such a pacemaker may sense R-wavesignals attendant to intrinsic ventricular depolarizations and deliverventricular pacing pulses in the absence of sensed R-waves. While singlechamber ventricular sensing and pacing by an intracardiac ventricularpacemaker may adequately address some patient conditions, some patientsmay benefit from atrial and ventricular (dual chamber) sensing forproviding atrial-synchronized ventricular pacing in order to maintain aregular heart rhythm.

SUMMARY

The techniques of this disclosure generally relate to a pacemaker havinga motion sensor producing a motion signal including ventricular andatrial event signals. The pacemaker is configured to sense atrial eventsfrom the motion signal. The sensed atrial events may be used forcontrolling atrial synchronized ventricular pacing pulses delivered bythe pacemaker in some examples. A pacemaker operating according to thetechniques disclosed herein determines one or more atrial event sensingparameters used for sensing the atrial event signals by determining afeature of the motion signal and setting the atrial event sensingparameter based on the feature determined over multiple ventricularcycles. In some examples, the atrial event sensing parameter is setbased on a distribution of the feature, e.g., based on a percentile or amedian, mean or other measure of centeredness of the distribution.

In one example, the disclosure provides a pacemaker including a pulsegenerator configured to generate pacing pulses which may be delivered toa ventricle of a patient's heart via electrodes coupled to thepacemaker. The pacemaker may include a sensing circuit comprising anR-wave detector for sensing R-waves from a cardiac electrical signal, amotion sensor including multiple axes where each axis is configured toproduce an axis signal, and a control circuit coupled to the motionsensor, the sensing circuit and the pulse generator. The control circuitis configured to identify ventricular events. Following each of theventricular events, the control circuit may set a sensing window. Foreach vector signal of multiple vector signals each including at leastone axis signal from the motion sensor, the control circuit maydetermine a maximum amplitude during multiple sensing windows. Thecontrol circuit may set an atrial event sensing vector signal based onthe determined maximum amplitudes. The pacemaker may sense the atrialevent from the selected atrial event sensing vector signal and producean atrial sensed event signal in response to sensing the atrial event.In some examples, the control circuit may start an atrioventricularpacing interval in response to sensing the atrial event and the pulsegenerator may generate a ventricular pacing pulse in response to theatrioventricular pacing interval expiring.

In another example, the disclosure provides a method including producingan axis signal from each axis of multiple axes of a motion sensor,identifying ventricular events and setting a sensing window followingeach of the ventricular events. The method further includes, for eachvector signal of multiple vector signals, determining a maximumamplitude of the vector signal during multiple sensing windows, whereeach vector signal includes at least one axis signal from the motionsensor. The method may further include selecting an atrial event sensingvector signal from vector signals based on the determined maximumamplitudes and sensing an atrial event from the selected atrial eventsensing vector signal. The method may include producing an atrial sensedevent signal in response to sensing the atrial event. In some examples,the method includes starting an atrioventricular pacing interval inresponse to the atrial sensed event signal and generating a ventricularpacing pulse in response to the atrioventricular pacing intervalexpiring.

In another example, the disclosure provides a non-transitory,computer-readable storage medium comprising a set of instructions which,when executed by a control circuit of a pacemaker, cause the pacemakerto produce an axis signal from each axis of a multi-axis motion sensor,identify ventricular events; set a sensing window following each of theventricular events, and, for each vector signal of multiple vectorsignals, determine a maximum amplitude of the vector signal duringmultiple sensing windows. Each vector signal includes at least one axissignal from the motion sensor. The instructions further cause thepacemaker to select an atrial event sensing vector signal from vectorsignals based on the determined maximum amplitudes, sense an atrialevent from the selected atrial event sensing vector signal, and producean atrial sensed event signal in response to sensing the atrial event.In some examples, the instructions further cause the pacemaker to startan atrioventricular pacing interval in response to the atrial sensedevent signal and generate a ventricular pacing pulse in response to theatrioventricular pacing interval expiring.

The details of one or more aspects of the disclosure are set forth inthe accompanying drawings and the description below. Other features,objects, and advantages of the techniques described in this disclosurewill be apparent from the description and drawings, and from the claims.

BRIEF DESCRIPTION OF DRAWINGS

FIG. 1 is a conceptual diagram illustrating a medical device system thatmay be used to sense cardiac electrical signals and motion signalsinduced by cardiac motion and flowing blood and provide pacing therapyto a patient's heart.

FIG. 2 is a conceptual diagram of the intracardiac pacemaker shown inFIG. 1.

FIG. 3 is a schematic diagram of an example configuration of thepacemaker shown in FIG. 1.

FIG. 4 is an example of a motion sensor signal that may be acquired by amotion sensor included in the pacemaker of FIG. 1 over a cardiac cycle.

FIG. 5 is an example of motion sensor signals acquired over twodifferent cardiac cycles.

FIG. 6 is a flow chart of a method for establishing atrial event sensingparameters.

FIG. 7 is a flow chart of a method for selecting an atrial event sensingvector according to one example.

FIG. 8 depicts two example histograms generated for two different motionsensor signal vectors.

FIG. 9 is a flow chart of a method for establishing an ending time of apassive ventricular filling window, also referred to herein as an “A3window.”

FIG. 10 is an example of a histogram of the latest threshold amplitudecrossing times during an extended A3 window.

FIG. 11 is a flow chart of a method for establishing early and latevalues of the atrial event sensing threshold amplitude to be appliedduring and after the passive ventricular filling window, respectfully.

FIG. 12 is one example of a histogram of motion signal maximumamplitudes used for establishing an early atrial event sensing thresholdamplitude.

FIG. 13 is one example of a histogram of motion signal maximumamplitudes for establishing a late atrial event sensing thresholdamplitude.

FIG. 14 is a flow chart of a method for controlling atrial-synchronizedventricular pacing according to one example.

FIG. 15 is a flow chart of a process performed by a pacemaker forsetting atrial event sensing parameters according to another example.

DETAILED DESCRIPTION

In general, this disclosure describes techniques for establishingcardiac event sensing parameters by an implantable medical device. Asdescribed below, atrial systolic events may be sensed from a signalproduced by a motion sensor that includes an atrial systolic eventsignal corresponding to atrial mechanical contraction and the activefilling phase of the ventricle, sometimes referred to as the “atrialkick.” The atrial event sensing parameters may include selecting avector signal of the motion sensor, a sensing threshold amplitude, andtime windows during which an atrial event can be sensed. The techniquesdisclosed herein provide techniques for sensing atrial events by aventricular pacemaker, which may be wholly implantable within aventricular heart chamber and having a motion sensor for producing anintraventricular motion signal. In this way, atrial events can bedetected from within the ventricle for use in controlling atrialsynchronized ventricular pacing, for example. Atrial-synchronizedventricular pacing pulses can be delivered by a pacemaker implanted inthe ventricle without requiring a sensor in or on the atria of thepatient's heart for detecting atrial events.

FIG. 1 is a conceptual diagram illustrating an implantable medicaldevice (IMD) system 10 that may be used to sense cardiac electricalsignals and motion signals induced by cardiac motion and flowing bloodand provide pacing therapy to a patient's heart 8. 1 MB system 10includes a ventricular intracardiac pacemaker 14. Pacemaker 14 may be atranscatheter intracardiac pacemaker which is adapted for implantationwholly within a heart chamber, e.g., wholly within the right ventricle(RV) or wholly within the left ventricle (LV) of heart 8 for sensingcardiac signals and delivering ventricular pacing pulses. Pacemaker 14may be reduced in size compared to subcutaneously implanted pacemakersand may be generally cylindrical in shape to enable transvenousimplantation via a delivery catheter.

Pacemaker 14 is shown positioned in the RV, along an endocardial wall,e.g., near the RV apex though other locations are possible. Thetechniques disclosed herein are not limited to the pacemaker locationshown in the example of FIG. 1 and other positions within heart 8 arepossible. For example, ventricular intracardiac pacemaker 14 may bepositioned in the LV and configured to detect cardiac motion signals anddeliver atrial-synchronized ventricular pacing to the LV using thetechniques disclosed herein. Pacemaker 14 may be positioned within theRV or LV to provide respective right ventricular or left ventricularpacing and for sensing cardiac motion signals by a motion sensor withinthe ventricular chamber.

Pacemaker 14 is capable of producing electrical stimulation pulses,e.g., pacing pulses, delivered to heart 8 via one or more electrodes onthe outer housing of the pacemaker. Pacemaker 14 is configured todeliver RV pacing pulses and sense an RV cardiac electrical signal usinghousing based electrodes for producing an RV electrogram (EGM) signal.The cardiac electrical signals may be sensed using the housing basedelectrodes that are also used to deliver pacing pulses to the RV.

Pacemaker 14 is configured to control the delivery of ventricular pacingpulses to the RV in a manner that promotes synchrony between atrialactivation and ventricular activation, e.g., by maintaining a targetatrioventricular (AV) interval between atrial events and ventricularpacing pulses. That is, pacemaker 14 controls pacing pulse delivery tomaintain a desired AV interval between atrial contractions correspondingto atrial systole and ventricular pacing pulses delivered to causeventricular depolarization and ventricular systole.

According to the techniques described herein, atrial systolic eventsproducing the active ventricular filling phase are detected by pacemaker14 from a motion sensor such as an accelerometer enclosed by the housingof pacemaker 14. The motion signal produced by an accelerometerimplanted within a ventricular chamber, which may be referred to as an“intraventricular motion signal,” includes motion signals caused byventricular and atrial events. For example, acceleration of bloodflowing into the RV through the tricuspid valve 16 between the RA and RVcaused by atrial systole, and referred to as the “atrial kick,” may bedetected by pacemaker 14 from the signal produced by an accelerometerincluded in pacemaker 14. Other motion signals that may be detected bypacemaker 14, such as motion caused by ventricular contraction andpassive ventricular filling are described below in conjunction with FIG.4.

Atrial P-waves that are attendant to atrial depolarization arerelatively low amplitude signals in the near-field ventricular cardiacelectrical signal received by pacemaker 14 (e.g., compared to thenear-field R-wave) and therefore can be difficult to reliably detectfrom the cardiac electrical signal acquired by pacemaker 14 implanted ina ventricular chamber. Atrial-synchronized ventricular pacing bypacemaker 14 or other functions that rely on atrial sensing may not bereliable when based solely on a cardiac electrical signal received bypacemaker 14. According to the techniques disclosed herein, pacemaker 14includes a motion sensor, such as an accelerometer, and is configured todetect an atrial event corresponding to atrial mechanical activation oratrial systole from a signal produced by the motion sensor. Ventricularpacing pulses may be synchronized to the atrial event that is detectedfrom the motion sensor signal by setting a programmable AV pacinginterval that controls the timing of the ventricular pacing pulserelative to the detected atrial systolic event. As described below,detection of the atrial systolic event used to synchronize ventricularpacing pulses to atrial systole may include detection of other cardiacevent motion signals in order to positively identify the atrial systolicevent.

A target AV interval may be a default value or a programmed valueselected by a clinician and is the time interval from the detection ofthe atrial event until delivery of the ventricular pacing pulse. In someinstances, the target AV interval may be started from the time theatrial systolic event is detected based on a motion sensor signal orstarting from an identified fiducial point of the atrial event signal.The target AV interval may be identified as being hemodynamicallyoptimal for a given patient based on clinical testing or assessments ofthe patient or based on clinical data from a population of patients. Thetarget AV interval may be determined to be optimal based on relativetiming of electrical and mechanical events as identified from thecardiac electrical signal received by pacemaker 14 and the motion sensorsignal received by pacemaker 14.

Pacemaker 14 may be capable of bidirectional wireless communication withan external device 20 for programming the AV pacing interval and otherpacing control parameters as well as cardiac event sensing parameters,which may be utilized for detecting ventricular mechanical events andthe atrial systolic event from the motion sensor signal. Aspects ofexternal device 20 may generally correspond to the externalprogramming/monitoring unit disclosed in U.S. Pat. No. 5,507,782(Kieval, et al.), hereby incorporated herein by reference in itsentirety. External device 20 is often referred to as a “programmer”because it is typically used by a physician, technician, nurse,clinician or other qualified user for programming operating parametersin pacemaker 14. External device 20 may be located in a clinic, hospitalor other medical facility. External device 20 may alternatively beembodied as a home monitor or a handheld device that may be used in amedical facility, in the patient's home, or another location. Operatingparameters, including sensing and therapy delivery control parameters,may be programmed into pacemaker 14 using external device 20.

External device 20 may include a processor 52, memory 53, display 54,user interface 56 and telemetry unit 58. Processor 52 controls externaldevice operations and processes data and signals received from pacemaker14. Display unit 54 may generate a display, which may include agraphical user interface, of data and information relating to pacemakerfunctions to a user for reviewing pacemaker operation and programmedparameters as well as cardiac electrical signals, cardiac motion signalsor other physiological data that may be acquired by pacemaker 14 andtransmitted to external device 20 during an interrogation session.

User interface 56 may include a mouse, touch screen, key pad or the liketo enable a user to interact with external device 20 to initiate atelemetry session with pacemaker 14 for retrieving data from and/ortransmitting data to pacemaker 14, including programmable parameters forcontrolling cardiac event sensing and therapy delivery. Telemetry unit58 includes a transceiver and antenna configured for bidirectionalcommunication with a telemetry circuit included in pacemaker 14 and isconfigured to operate in conjunction with processor 52 for sending andreceiving data relating to pacemaker functions via communication link24.

At the time of implant, during patient follow-up visits, or any timeafter pacemaker implantation, pacemaker 14 may perform a set-upprocedure to establish parameters used in detecting atrial events fromthe motion sensor signal. The patient may be standing, sitting, lyingdown or ambulatory during the process. The set-up procedure may includeacquiring motion sensor signal data and generating distributions ofmotion sensor signal features for establishing atrial event sensingparameters. Motion sensor signal data may be transmitted to externaldevice 20 and displayed on display unit 54 of external device 20 in theform of a histogram in some examples. The atrial event sensingparameters established based on the motion sensor signal data may be setautomatically or may be transmitted to external device 20 for generatinga display on display unit 54 as recommended parameters, allowing aclinician to review and accept or modify the recommended parameters,e.g., using user interface 56.

In some examples, external device processor 52 may execute operationsdisclosed herein for establishing a starting value of an atrial eventsensing parameter based on data retrieved from pacemaker 14. Processor52 may cause display unit 54 to generate a display of data relating to amotion sensor signal, including histogram distributions of metricsdetermined from a cardiac motion signal for use in selecting startingvalues of atrial event sensing control parameters. Display unit 54 maybe a graphical user interface that enables a user to interact with thedisplay, e.g., for selecting various displays or information forviewing. In some examples, a user may select one or more atrial eventsensing control parameter settings to be automatically established bypacemaker 14 and/or may program starting sensing control parameters orother programmable parameters for controlling sensor operation andtherapy delivery. Processing circuitry included in pacemaker 14 and/orprocessor 52 may determine starting values for one or more atrialsystolic event sensing control parameters based on data acquired frommotion sensor signals produced by an accelerometer included in pacemaker14 and various thresholds and criteria, which may include userprogrammable thresholds or criteria used in setting the startingparameter values.

External device telemetry unit 58 is configured for bidirectionalcommunication with implantable telemetry circuitry included in pacemaker14. Telemetry unit 58 establishes a wireless communication link 24 withpacemaker 14. Communication link 24 may be established using a radiofrequency (RF) link such as BLUETOOTH®, Wi-Fi, Medical ImplantCommunication Service (MICS) or other communication bandwidth. In someexamples, external device 20 may include a programming head that isplaced proximate pacemaker 14 to establish and maintain a communicationlink 24, and in other examples external device 20 and pacemaker 14 maybe configured to communicate using a distance telemetry algorithm andcircuitry that does not require the use of a programming head and doesnot require user intervention to maintain a communication link. Anexample RF telemetry communication system that may be implemented insystem 10 is generally disclosed in U.S. Pat. No. 5,683,432 (Goedeke, etal.), hereby incorporated herein by reference in its entirety.

It is contemplated that external device 20 may be in wired or wirelessconnection to a communications network via a telemetry circuit thatincludes a transceiver and antenna or via a hardwired communication linefor transferring data to a centralized database or computer to allowremote management of the patient. Remote patient management systemsincluding a centralized patient database may be configured to utilizethe presently disclosed techniques to enable a clinician to review EGM,motion sensor signal, and marker channel data and authorize programmingof sensing and therapy control parameters in pacemaker 14, e.g., afterviewing a visual representation of EGM, motion sensor signal and markerchannel data.

FIG. 2 is a conceptual diagram of the intracardiac pacemaker 14 shown inFIG. 1. Pacemaker 14 includes electrodes 162 and 164 spaced apart alongthe housing 150 of pacemaker 14 for sensing cardiac electrical signalsand delivering pacing pulses. Electrode 164 is shown as a tip electrodeextending from a distal end 102 of pacemaker 14, and electrode 162 isshown as a ring electrode along a mid-portion of housing 150, forexample adjacent proximal end 104. Distal end 102 is referred to as“distal” in that it is expected to be the leading end as pacemaker 14 isadvanced through a delivery tool, such as a catheter, and placed againsta targeted pacing site.

Electrodes 162 and 164 form an anode and cathode pair for bipolarcardiac pacing and sensing. In alternative embodiments, pacemaker 14 mayinclude two or more ring electrodes, two tip electrodes, and/or othertypes of electrodes exposed along pacemaker housing 150 for deliveringelectrical stimulation to heart 8 and sensing cardiac electricalsignals. Electrodes 162 and 164 may be, without limitation, titanium,platinum, iridium or alloys thereof and may include a low polarizingcoating, such as titanium nitride, iridium oxide, ruthenium oxide,platinum black among others. Electrodes 162 and 164 may be positioned atlocations along pacemaker 14 other than the locations shown.

Housing 150 is formed from a biocompatible material, such as a stainlesssteel or titanium alloy. In some examples, the housing 150 may includean insulating coating. Examples of insulating coatings include parylene,urethane, PEEK, or polyimide among others. The entirety of the housing150 may be insulated, but only electrodes 162 and 164 uninsulated.Electrode 164 may serve as a cathode electrode and be coupled tointernal circuitry, e.g., a pacing pulse generator and cardiacelectrical signal sensing circuitry, enclosed by housing 150 via anelectrical feedthrough crossing housing 150. Electrode 162 may be formedas a conductive portion of housing 150 defining a ring electrode that iselectrically isolated from the other portions of the housing 150 asgenerally shown in FIG. 2. In other examples, the entire periphery ofthe housing 150 may function as an electrode that is electricallyisolated from tip electrode 164, instead of providing a localized ringelectrode such as anode electrode 162. Electrode 162 formed along anelectrically conductive portion of housing 150 serves as a return anodeduring pacing and sensing.

The housing 150 includes a control electronics subassembly 152, whichhouses the electronics for sensing cardiac signals, producing pacingpulses and controlling therapy delivery and other functions of pacemaker14 as described below in conjunction with FIG. 3. A motion sensor may beimplemented as an accelerometer enclosed within housing 150 in someexamples. The accelerometer provides a signal to a processor included incontrol electronics subassembly 152 for signal processing and analysisfor detecting atrial systolic events, e.g., for use in controlling thetiming ventricular pacing pulses, as described below.

The accelerometer may be a three-dimensional accelerometer. In someexamples, the accelerometer may have one “longitudinal” axis that isparallel to or aligned with the longitudinal axis 108 of pacemaker 14and two orthogonal axes that extend in radial directions relative to thelongitudinal axis 108. Practice of the techniques disclosed herein,however, are not limited to a particular orientation of theaccelerometer within or along housing 150. In other examples, aone-dimensional accelerometer may be used to obtain an intracardiacmotion signal from which atrial systolic events are detected. In stillother examples, a two dimensional accelerometer or othermulti-dimensional accelerometer may be used. Each axis of a single ormulti-dimensional accelerometer may be defined by a piezoelectricelement, micro-electrical mechanical system (MEMS) device or othersensor element capable of producing an electrical signal in response tochanges in acceleration imparted on the sensor element, e.g., byconverting the acceleration to a force or displacement that is convertedto the electrical signal. In a multi-dimensional accelerometer, thesensor elements may be arranged orthogonally with each sensor elementaxis orthogonal relative to the other sensor element axes. Orthogonalarrangement of the elements of a multi-axis accelerometer, however, isnot necessarily required.

Each sensor element may produce an acceleration signal corresponding toa vector aligned with the axis of the sensor element. As describedbelow, techniques disclosed herein include selecting a vector signal ofa multi-dimensional accelerometer (also referred to as a “multi-axis”accelerometer) for use in sensing atrial systolic events. In some casesone, two or all three axis signals produced by a three dimensionalaccelerometer may be selected as a vector signal for use in detectingatrial systolic events, e.g., for controlling atrial-synchronizedventricular pacing delivered by pacemaker 14.

Housing 150 further includes a battery subassembly 160, which providespower to the control electronics subassembly 152. Battery subassembly160 may include features of the batteries disclosed in commonly-assignedU.S. Pat. No. 8,433,409 (Johnson, et al.) and U.S. Pat. No. 8,541,131(Lund, et al.), both of which are hereby incorporated by referenceherein in their entirety.

Pacemaker 14 may include a set of fixation tines 166 to secure pacemaker14 to patient tissue, e.g., by actively engaging with the ventricularendocardium and/or interacting with the ventricular trabeculae. Fixationtines 166 are configured to anchor pacemaker 14 to position electrode164 in operative proximity to a targeted tissue for deliveringtherapeutic electrical stimulation pulses. Numerous types of activeand/or passive fixation members may be employed for anchoring orstabilizing pacemaker 14 in an implant position. Pacemaker 14 mayinclude a set of fixation tines as disclosed in commonly-assigned U.S.Pat. No. 9,775,872 (Grubac, et al.), hereby incorporated herein byreference in its entirety.

Pacemaker 14 may optionally include a delivery tool interface 158.Delivery tool interface 158 may be located at the proximal end 104 ofpacemaker 14 and is configured to connect to a delivery device, such asa catheter, used to position pacemaker 14 at an implant location duringan implantation procedure, for example within a heart chamber.

FIG. 3 is a schematic diagram of an example configuration of pacemaker14 shown in FIG. 1. Pacemaker 14 includes a pulse generator 202, acardiac electrical signal sensing circuit 204, a control circuit 206,memory 210, telemetry circuit 208, motion sensor 212 and a power source214. The various circuits represented in FIG. 3 may be combined on oneor more integrated circuit boards which include a specific integratedcircuit (ASIC), an electronic circuit, a processor (shared, dedicated,or group) and memory that execute one or more software or firmwareprograms, a combinational logic circuit, state machine or other suitablecomponents that provide the described functionality.

Motion sensor 212 may include an accelerometer in the examples describedherein. Motion sensor 212 is not limited to being an accelerometer,however, and other motion sensors may be utilized successfully inpacemaker 14 for detecting cardiac motion signals according to thetechniques described herein. Examples of motion sensors that may beimplemented in motion sensor 212 include piezoelectric sensors and MEMSdevices.

Motion sensor 212 may include a multi-axis sensor, e.g., atwo-dimensional or three-dimensional sensor, with each axis providing anaxis signal that may be analyzed individually or in combination fordetecting cardiac mechanical events. Motion sensor 212 produces anelectrical signal correlated to motion or vibration of sensor 212 (andpacemaker 14), e.g., when subjected to flowing blood and cardiac motion.The motion sensor 212 may include one or more filter, amplifier,rectifier, analog-to-digital converter (ADC) and/or other components forproducing a motion signal that is passed to control circuit 206. Forexample, each vector signal produced by each individual axis of amulti-axis accelerometer may be filtered by a high pass filter, e.g., a10 Hz high pass filter. The filtered signal may be digitized by an ADCand rectified for use by atrial event detector circuit 240 for detectingatrial systolic events. The high pass filter may be lowered (e.g., to 5Hz) if needed to detect atrial signals that have lower frequencycontent. In some examples, high pass filtering is performed with no lowpass filtering. In other examples, each accelerometer axis signal isfiltered by a low pass filter, e.g., a 30 Hz low pass filter, with orwithout high pass filtering.

One example of an accelerometer for use in implantable medical devicesthat may be implemented in conjunction with the techniques disclosedherein is generally disclosed in U.S. Pat. No. 5,885,471 (Ruben, etal.), incorporated herein by reference in its entirety. An implantablemedical device arrangement including a piezoelectric accelerometer fordetecting patient motion is disclosed, for example, in U.S. Pat. No.4,485,813 (Anderson, et al.) and U.S. Pat. No. 5,052,388 (Sivula, etal.), both of which patents are hereby incorporated by reference hereinin their entirety. Examples of three-dimensional accelerometers that maybe implemented in pacemaker 14 and used for detecting cardiac mechanicalevents using the presently disclosed techniques are generally describedin U.S. Pat. No. 5,593,431 (Sheldon) and U.S. Pat. No. 6,044,297(Sheldon), both of which are incorporated herein by reference in theirentirety. Other accelerometer designs may be used for producing anelectrical signal that is correlated to motion imparted on pacemaker 14due to ventricular and atrial events.

Sensing circuit 204 is configured to receive a cardiac electrical signalvia electrodes 162 and 164 by a pre-filter and amplifier circuit 220.Pre-filter and amplifier circuit may include a high pass filter toremove DC offset, e.g., a 2.5 to 5 Hz high pass filter, or a widebandfilter having a passband of 2.5 Hz to 100 Hz to remove DC offset andhigh frequency noise. Pre-filter and amplifier circuit 220 may furtherinclude an amplifier to amplify the “raw” cardiac electrical signalpassed to analog-to-digital converter (ADC) 226. ADC 226 may pass amulti-bit, digital electrogram (EGM) signal to control circuit 206 foruse by atrial event detector circuit 240 in identifying ventricularelectrical events (e.g., R-waves or T-waves) and/or atrial electricalevents, e.g., P-waves. Identification of cardiac electrical events maybe used in algorithms for establishing atrial sensing control parametersand for detecting atrial systolic events from the motion sensor signal.The digital signal from ADC 226 may be passed to rectifier and amplifiercircuit 222, which may include a rectifier, bandpass filter, andamplifier for passing a cardiac signal to R-wave detector 224.

R-wave detector 224 may include a sense amplifier or other detectioncircuitry that compares the incoming rectified, cardiac electricalsignal to an R-wave sensing threshold, which may be an auto-adjustingthreshold. When the incoming signal crosses the R-wave sensingthreshold, the R-wave detector 224 produces an R-wave sensed eventsignal (R-sense) that is passed to control circuit 206. In otherexamples, R-wave detector 224 may receive the digital output of ADC 226for detecting R-waves by a comparator, morphological signal analysis ofthe digital EGM signal or other R-wave detection techniques. Processor244 may provide sensing control signals to sensing circuit 204, e.g.,R-wave sensing threshold, sensitivity, and various blanking andrefractory intervals applied to the cardiac electrical signal forcontrolling R-wave sensing. R-wave sensed event signals passed fromR-wave detector 224 to control circuit 206 may be used for schedulingventricular pacing pulses by pace timing circuit 242 and for use inidentifying the timing of ventricular electrical events in algorithmsperformed by atrial event detector circuit 240 for detecting atrialsystolic events from a signal received from motion sensor 212.

Control circuit 206 includes an atrial event detector circuit 240, pacetiming circuit 242, and processor 244. Control circuit 206 may receiveR-wave sensed event signals and/or digital cardiac electrical signalsfrom sensing circuit 204 for use in detecting and confirming cardiacevents and controlling ventricular pacing. For example, R-wave sensedevent signals may be passed to pace timing circuit 242 for inhibitingscheduled ventricular pacing pulses or scheduling ventricular pacingpulses when pacemaker 14 is operating in a non-atrial trackingventricular pacing mode. R-wave sensed event signals may also be passedto atrial event detector circuit 240 for use in setting time windowsused by control circuit 206 in detecting atrial systolic events from themotion sensor signal.

Atrial event detector circuit 240 is configured to detect atrialsystolic events from a signal received from motion sensor 212.Techniques for setting time windows used in detecting atrial systolicevents are described below, e.g., in conjunction with FIGS. 9-10. Insome examples, one or more ventricular mechanical events may be detectedfrom the motion sensor signal in a given cardiac cycle to facilitatepositive detection of the atrial systolic event from the motion sensorsignal during the ventricular cycle.

Atrial event detector circuit 240 receives a motion signal from motionsensor 212 and may start an atrial “blanking” period in response to aventricular electrical event, e.g., an R-wave sensed event signal fromsensing circuit 204 or delivery of a pacing pulse by pulse generator202. The blanking period may correspond to a time period after theventricular electrical event during which ventricular mechanical events,e.g., corresponding to ventricular contraction and isovolumic relaxationare expected to occur. When ventricular pacing is properly synchronizedto atrial events, an atrial event is not expected to occur during theatrial blanking period, corresponding to ventricular systole. The motionsignal peaks that occur during the atrial blanking period, therefore,are not sensed as atrial events. The atrial “blanking” period may beused to define a time period following a ventricular electrical eventduring which an atrial systolic event is not sensed by atrial eventdetector circuit 240. The motion sensor signal, however, is notnecessarily blanked during this time period in that control circuit 206may still receive the motion sensor signal during the atrial blankingperiod and may process the motion signal for sensing ventricular eventsduring the atrial blanking period in some examples.

Atrial event detector circuit 240 determines if the motion sensor signalsatisfies atrial systolic event detection criteria outside of the atrialblanking period. The motion sensor signal during the blanking period maybe monitored by atrial event detector circuit 240 for the purposes ofdetecting ventricular mechanical events, which may be used forconfirming or validating atrial systolic event detection in someexamples. As such, ventricular mechanical event detection windows may beset during the atrial blanking period and may be set according topredetermined time intervals following identification of a ventricularelectrical event. Atrial event detector circuit 240 may be configured todetect one or more ventricular mechanical events during respectiveventricular event detection windows during the atrial blanking period.The timing and detection of the ventricular mechanical events may beused to update the atrial blanking period and/or may be used to confirmdetection of the atrial event occurring subsequent to expectedventricular mechanical events.

Atrial event detector circuit 240 may set time windows corresponding tothe passive ventricular filling phase and the active ventricular fillingphase based on the timing of a preceding ventricular electrical event,either an R-wave sensed event signal or a ventricular pacing pulse. Amotion sensor signal crossing of an atrial event sensing thresholdduring either of these windows may be detected as the atrial systolicevent. As described below, two different atrial event sensing thresholdvalues may be established for applying during the passive filling phasewindow and after the passive filling phase window (during an activefilling phase window also referred to below as an “A4 window”).

Atrial event detector circuit 240 passes an atrial event detectionsignal to processor 244 and/or pace timing circuit 242 in response todetecting an atrial event. Pace timing circuit 242 (or processor 244)may additionally receive R-wave sensed event signals from R-wavedetector 224 for use in controlling the timing of pacing pulsesdelivered by pulse generator 202. Processor 244 may include one or moreclocks for generating clock signals that are used by pace timing circuit242 to time out an AV pacing interval that is started upon receipt of anatrial event detection signal from atrial event detector circuit 240.Pace timing circuit 242 may include one or more pacing escape intervaltimers or counters that are used to time out the AV pacing interval,which may be a programmable interval stored in memory 210 and retrievedby processor 244 for use in setting the AV pacing interval used by pacetiming circuit 242. One application of atrial sensed event signalsproduced by atrial event detector circuit 240 is for setting AV pacingintervals for controlling the timing of ventricular pacing pulses.Control circuit 206, however, may use atrial sensed event signals forother purposes.

Pace timing circuit 242 may additionally include a lower pacing rateinterval timer for controlling a minimum ventricular pacing rate. Forexample, if an atrial systolic event is not detected from the motionsensor signal triggering a ventricular pacing pulse at the programmed AVpacing interval, a ventricular pacing pulse may be delivered by pulsegenerator 202 upon expiration of the lower pacing rate interval toprevent ventricular asystole and maintain a minimum ventricular rate. Attimes, control circuit 206 may control pulse generator 202 in anon-atrial tracking ventricular pacing mode (also referred to as“asynchronous ventricular pacing”) during a process for establishingsensing parameters used for detecting atrial systolic events from themotion signal. The non-atrial tracking ventricular pacing mode may bedenoted as a VDI pacing mode in which ventricular pacing pulses aredelivered in the absence of a sensed R-wave and inhibited in response toan R-wave sensed event signal from sensing circuit 204. Dual chambersensing may be performed during the non-atrial tracking ventricularpacing mode by sensing ventricular electrical events by sensing circuit204 and sensing atrial systolic events from the motion signal receivedby atrial event detector circuit 240 from motion sensor 212. Asdescribed below in conjunction with FIGS. 7-14, atrial event sensingparameters established during a VDI pacing mode may include an atrialevent sensing vector of the motion sensor producing a signal from whichthe atrial systolic event is detected, the end of a passive ventricularfilling window, and the atrial event sensing threshold amplitude valuesapplied during and after the passive ventricular filling window.

Pulse generator 202 generates electrical pacing pulses that aredelivered to the RV of the patient's heart via cathode electrode 164 andreturn anode electrode 162. In addition to providing control signals topace timing circuit 242 and pulse generator 202 for controlling thetiming of ventricular pacing pulses, processor 244 may retrieveprogrammable pacing control parameters, such as pacing pulse amplitudeand pacing pulse width, which are passed to pulse generator 202 forcontrolling pacing pulse delivery. Pulse generator 202 may includecharging circuit 230, switching circuit 232 and an output circuit 234.

Charging circuit 230 may include a holding capacitor that may be chargedto a pacing pulse amplitude by a multiple of the battery voltage signalof power source 214 under the control of a voltage regulator. The pacingpulse amplitude may be set based on a control signal from controlcircuit 206. Switching circuit 232 may control when the holdingcapacitor of charging circuit 230 is coupled to the output circuit 234for delivering the pacing pulse. For example, switching circuit 232 mayinclude a switch that is activated by a timing signal received from pacetiming circuit 242 upon expiration of an AV pacing interval (or VV lowerrate pacing interval) and kept closed for a programmed pacing pulsewidth to enable discharging of the holding capacitor of charging circuit230. The holding capacitor, previously charged to the pacing pulsevoltage amplitude, is discharged across electrodes 162 and 164 throughthe output capacitor of output circuit 234 for the programmed pacingpulse duration. Examples of pacing circuitry generally disclosed in U.S.Pat. No. 5,507,782 (Kieval, et al.) and in U.S. Pat. No. 8,532,785(Crutchfield, et al.), both of which patents are incorporated herein byreference in their entirety, may be implemented in pacemaker 14 forcharging a pacing capacitor to a predetermined pacing pulse amplitudeunder the control of control circuit 206 and delivering a pacing pulse.

Memory 210 may include computer-readable instructions that, whenexecuted by control circuit 206, cause control circuit 206 to performvarious functions attributed throughout this disclosure to pacemaker 14.The computer-readable instructions may be encoded within memory 210.Memory 210 may include any non-transitory, computer-readable storagemedia including any volatile, non-volatile, magnetic, optical, orelectrical media, such as a random access memory (RAM), read-only memory(ROM), non-volatile RAM (NVRAM), electrically-erasable programmable ROM(EEPROM), flash memory, or other digital media with the sole exceptionbeing a transitory propagating signal. Memory 210 may store timingintervals and other data used by control circuit 206 to control thedelivery of pacing pulses by pulse generator 202, e.g., by detecting anatrial event by atrial event detector circuit 240 from the motion sensorsignal and setting a pacing escape interval timer included in pacetiming circuit 242, according to the techniques disclosed herein.

Power source 214 provides power to each of the other circuits andcomponents of pacemaker 14 as required. Power source 214 may include oneor more energy storage devices, such as one or more rechargeable ornon-rechargeable batteries. The connections between power source 214 andother pacemaker circuits and components are not shown in FIG. 3 for thesake of clarity but are to be understood from the general block diagramof FIG. 3. For example, power source 214 may provide power as needed tocharging and switching circuitry included in pulse generator 202,amplifiers, ADC 226 and other components of sensing circuit 204,telemetry circuit 208, memory 210, and motion sensor 212.

Telemetry circuit 208 includes a transceiver 209 and antenna 211 fortransferring and receiving data via a radio frequency (RF) communicationlink. Telemetry circuit 208 may be capable of bi-directionalcommunication with external device 20 (FIG. 1) as described above.Motion sensor signals and cardiac electrical signals, and/or dataderived therefrom may be transmitted by telemetry circuit 208 toexternal device 20. Programmable control parameters and algorithms forperforming atrial event detection and ventricular pacing control may bereceived by telemetry circuit 208 and stored in memory 210 for access bycontrol circuit 206.

The functions attributed to pacemaker 14 herein may be embodied as oneor more processors, controllers, hardware, firmware, software, or anycombination thereof. Depiction of different features as specificcircuitry is intended to highlight different functional aspects and doesnot necessarily imply that such functions must be realized by separatehardware, firmware or software components or by any particular circuitarchitecture. Rather, functionality associated with one or more circuitsdescribed herein may be performed by separate hardware, firmware orsoftware components, or integrated within common hardware, firmware orsoftware components. For example, atrial systolic event detection fromthe motion sensor signal and ventricular pacing control operationsperformed by pacemaker 14 may be implemented in control circuit 206executing instructions stored in memory 210 and relying on input fromsensing circuit 204 and motion sensor 212. Providing software, hardware,and/or firmware to accomplish the described functionality in the contextof any modern pacemaker, given the disclosure herein, is within theabilities of one of skill in the art.

FIG. 4 is an example of a motion sensor signal 250 that may be acquiredby motion sensor 212 over a cardiac cycle. Vertical dashed lines 252 and262 denote the timing of two consecutive ventricular events (anintrinsic ventricular depolarization or a ventricular pacing pulse),marking the respective beginning and end of the ventricular cycle 251.The motion signal includes an A1 event 254, an A2 event 256, an A3 event258 and an A4 event 260. The A1 event 254 is an acceleration signal (inthis example when motion sensor 212 is implemented as an accelerometer)that occurs during ventricular contraction and marks the approximateonset of ventricular mechanical systole. The A1 event is also referredto herein as a “ventricular contraction event.” The A2 event 256 is anacceleration signal that may occur with closure of the aortic andpulmonic valves, marking the approximate offset or end of ventricularmechanical systole. The A2 event may also mark the beginning of theisovolumic relaxation phase of the ventricles that occurs with aorticand pulmonic valve closure.

The A3 event 258 is an acceleration signal that occurs during passiveventricular filling and marks ventricular mechanical diastole. The A3event is also referred to herein as the “A3 signal” and as the“ventricular passive filling event.” Since the A2 event occurs with theend of ventricular systole, it is an indicator of the onset ofventricular diastole. The A3 event occurs during ventricular diastole.As such, the A2 and A3 events may be collectively referred to asventricular mechanical diastolic events because they are both indicatorsof the ventricular diastolic period.

The A4 event 260 is an acceleration signal that occurs during atrialcontraction and active ventricular filling and marks atrial mechanicalsystole. The A4 event 260 is also referred to herein as the “A4 signal”and is the “atrial systolic event” or merely the “atrial event” that isdetected from motion sensor signal 250. Atrial event detector circuit240 detects A4 event 260. Processor 244 may control pace timing circuit242 to trigger a ventricular pacing pulse by starting an AV pacinginterval in response to detecting the A4 event 260. Control circuit 206may be configured to detect one or more of the A1, A2, and A3 eventsfrom motion sensor signal 250, for at least some ventricular cardiaccycles, for use in positively detecting the A4 event 260 and settingatrial event detection control parameters. The A1, A2 and/or A3 eventsmay be detected and characterized to avoid false detection of A4 eventsand promote reliable A4 event detection for proper timing ofatrial-synchronized ventricular pacing pulses.

Techniques described in conjunction with FIGS. 6-13 may be performed bypacemaker 14 for establishing parameters used for detecting A4 events,without necessarily requiring identification and discrimination of theA1-A4 events. Instead, the motion signal acquired during a non-atrialtracking ventricular pacing mode may be characterized by determiningfeatures of the motion signal during a sensing window and/or outside anatrial blanking period. Distributions of the features are used inestablishing atrial event sensing parameters.

FIG. 5 is an example of motion sensor signals 400 and 410 acquired overtwo different cardiac cycles. A ventricular pacing pulse is delivered attime 0.0 seconds for both cardiac cycles. The top sensor signal 400 isreceived over one cardiac cycle, and the bottom sensor signal 410 isreceived over a different cardiac cycle. The two signals 400 and 410 arealigned in time at 0.0 seconds, the time of the ventricular pacing pulsedelivery. While motion signals 400 and 410 and motion signal 250 of FIG.4 are shown as raw accelerometer signals, it is recognized that controlcircuit 206 may receive a digitized filtered, amplified and rectifiedsignal from motion sensor 212 for processing and analysis as describedin conjunction with the flow charts and histogram distributionspresented in the accompanying drawings.

The A1 events 402 and 412 of the respective motion sensor signals 400and 410, which occur during ventricular contraction, are observed to bewell-aligned in time following the ventricular pacing pulse at time 0.0seconds. Similarly, the A2 events 404 and 414 (which may mark the end ofventricular systole and the isovolumic ventricular relaxation phase) andthe A3 events 406 and 416 (occurring during passive ventricular filling)are well-aligned in time. Since the A1, A2 and A3 events are ventricularevents, occurring during ventricular contraction, at the end ofventricular systole and start of isovolumic ventricular relaxation andduring passive ventricular filling, respectively, these events areexpected to occur at relatively consistent intervals following aventricular electrical event, the ventricular pacing pulse in thisexample, and relative to each other. The time relationship of the A1, A2and A3 events may be different following a ventricular pacing pulsecompared to following a sensed intrinsic R-wave, however, during astable paced or intrinsic ventricular rhythm, the relative timing ofventricular A1, A2 and A3 events to each other and the immediatelypreceding ventricular electrical event is expected to be consistent frombeat-to-beat.

The A4 events 408 and 418 of the first and second motion sensor signals400 and 410 respectively are not aligned in time. The A4 event occursduring atrial systole and as such the time interval of the A4 eventfollowing the immediately preceding ventricular electrical event (sensedR-wave or ventricular pacing pulse) and the preceding A1 through A3events may vary between cardiac cycles.

The consistency of the timing of the A1 through A3 events relative toeach other and the immediately preceding ventricular electrical eventmay be used for determining an atrial blanking period 436 and increasingconfidence in reliably detecting A4 events 408 and 418. The atrialsystolic event is not detected during the atrial blanking period 436which extends from the ventricular electrical event (at time 0.0)through an estimated onset of ventricular diastole so that the atrialblanking period 436 includes both the A1 and A2 events. An A3 window 424may be set having a starting time 420 corresponding to the end of thepost-ventricular atrial blanking period 436 and an ending time 422. Theending time 422 may be established using techniques described below inconjunction with FIGS. 9 and 10. The ending time 422 may also beconsidered a starting time of an A4 sensing window 450, though A4signals may be sensed during the A3 window in some instances.

A4 events 408 and 418 may be detected based on a multi-level A4 sensingthreshold 444. As seen by the lower motion sensor signal 410, the A4event 418 may occur earlier after the A3 window 424 due to changes inatrial rate. In some instances, as the atrial rate increases, the A4event 418 may occur within the A3 window 424. When this occurs, the A3event 416 and the A4 event 418 may fuse as passive and activeventricular filling occur together. The fused A3/A4 event may have ahigh amplitude, even greater than the amplitude of either the A3 event416 or the A4 event 418 when they occur separately. As such, in someexamples a first, higher A4 sensing threshold amplitude 446 may beestablished for detecting an early A4 signal that is fused with the A3signal during the A3 window 424. A second, lower A4 sensing thresholdamplitude 448 may be established for detecting relatively later A4signals, after the ending time 422 of the A3 window 424, during an A4window 450. The A4 window 450 extends from the ending time of the A3window 424 until the next ventricular electrical event, sensed or paced.The earliest crossing of the A4 sensing threshold 444 by the motionsensor signal after the starting time 420 of the A3 window (or after theexpiration of the atrial blanking period 436) may be detected as theatrial systolic event. Techniques for establishing an early A4 sensingthreshold amplitude 446 used during the A3 window 424 and a late A4sensing threshold amplitude 448 used after the ending time 422 of the A3window 424, during the A4 window 450, are described below in conjunctionwith FIGS. 11-13.

FIG. 6 is a flow chart 300 of a method for establishing atrial eventsensing parameters. Control circuit 206 may perform the method of flowchart 300 to automatically select and set starting values of atrialevent sensing parameters used to in sensing A4 events from the motionsensor signal during an atrial tracking ventricular pacing mode. Theprocess of flow chart 300 may be performed by control circuit 206 uponimplantation of pacemaker 14 and may be performed at other post-implanttimes for updating or resetting an A4 sensing parameter.

At block 302, control circuit 206 sets the pacing mode to a non-atrialtracking ventricular pacing mode (e.g., VDI) so that ventricular pacingpulses are being delivered asynchronously to atrial events. The pacingrate may be set to a nominal rate, e.g., 50 pulses per minute. In someexamples, the ventricular pacing mode may be a rate responsive mode(e.g., VDIR), but the method for establishing the atrial event sensingparameters may be performed when the pacing rate is at or near theprogrammed lower rate, e.g., 40 to 60 pulses per minute. In a patienthaving AV block, atrial systolic events occur asynchronously withventricular electrical events during the non-atrial tracking pacingmode. Ventricular electrical events will generally be deliveredventricular pacing pulses in a patient with AV block, but may includeintrinsic R-waves in some instances and in a patient with AV conductionintact. As such, atrial events may course through the ventricularcardiac cycle at varying times during the VDI pacing mode.

For each available sensing vector of the multi-axis motion sensor,motion sensor signal data is acquired during the non-atrial trackingventricular pacing mode. Aspects of the motion sensor signal outside apost-ventricular atrial blanking period (or later than a minimum A3window starting time) may be determined to characterize motion sensorsignal features over the passive and active filling phases of eachventricular cycle for each available sensing vector. For example, atblock 304, control circuit 206 may determine at least one maximum motionsensor signal amplitude in each ventricular cycle (outside thepost-ventricular atrial blanking period) and the time of the latestcrossing of a nominal threshold amplitude by the motion sensor signal.The data acquired at block 304 may be acquired during each ventricularcycle over a predetermined time interval or predetermined number ofventricular cycles. For instance, control circuit 206 may acquire datafrom the motion sensor signal for several minutes, up to one hour or upto 24 hours for characterizing aspects of the motion sensor signal ineach of one or more sensing vectors of the motion sensor. In otherexamples, at least N values of a motion signal feature during arespective number of N ventricular cycles are determined.

At block 306, control circuit 206 generates one or more distributions ofthe amplitude and/or timing data acquired at block 304. In someexamples, the distribution(s) is/are generated as histogram(s). Ahistogram of maximum amplitude data may be generated for each availablesensing vector, for example, for selecting a sensing vector orcombination of vectors of the motion sensor from which atrial eventsensing is performed during an atrial tracking ventricular pacing mode.Techniques for generating a distribution of motion sensor maximumamplitude data and selecting a sensing vector are described below inconjunction with FIGS. 7 and 8.

In another example, a histogram of the latest crossing time of anamplitude threshold during each ventricular cycle may be generated atblock 306 for use in establishing an ending time of the A3 window (alsoreferred to as the passive ventricular filling window). Exampletechniques for generating a distribution and establishing the A3 windowending time are described below in conjunction with FIGS. 9 and 10.

A distribution in the form of a histogram of maximum amplitude data maybe generated at block 306 for use in establishing an early A4 sensingthreshold amplitude value and a late A4 sensing threshold amplitudevalue of a multi-level A4 sensing threshold used for sensing A4 eventsduring an atrial-tracking ventricular pacing mode. Techniques forgenerating histograms for establishing atrial event sensing thresholdvalues are described below in conjunction with FIGS. 11-13.

At block 308, control circuit 206 analyzes one or more distributions ofmotion sensor signal feature data for establishing one or more atrialevent sensing control parameters. Based on the distribution analysis,control circuit 206 may select an atrial event sensing parameter, whichmay include a motion sensor vector signal or combination of vectorsignals from which A4 signals are sensed during the atrial trackingpacing mode. Among other atrial event sensing parameters that may bederived from the generated distribution(s) of motion signal features arean ending time of the A3 window and the early sensing thresholdamplitude and the late sensing threshold amplitude of the multi-level A4sensing threshold. Various examples of techniques for acquiring datafrom the motion signal, generating distributions of the motion signaldata and deriving one or more atrial event sensing parameters from thedistributions are described below in conjunction with FIGS. 7-13.

FIG. 7 is a flow chart 500 of a method for selecting an A4 sensingvector according to one example. Control circuit 206 may control theprocess of flow chart 500 to set an initial sensing vector during anearly post-operative period after pacemaker implantation and may repeatthe process to reset an A4 sensing vector selection after a specifiedinterval of time or when A4 events are being undersensed (e.g., whenthreshold number of ventricular pacing pulses delivered at the ratesmoothing interval during the atrial tracking ventricular pacing mode).The A4 sensing vector selection process of flow chart 500 is performedfor determining which vector signal (from one axis or a combination ofaxes) of a multi-axis motion sensor produces a motion signal from whichatrial events can be sensed most reliably, e.g., based on atrial eventsignal strength.

At block 502, control circuit 206 sets the pacing mode of pacemaker 14to a non-atrial tracking ventricular pacing mode (e.g., VDI). Controlcircuit 206 may set the ventricular pacing interval (VV interval)according to a nominal pacing rate, e.g., 50 pulses per minute, in orderto maintain a minimum, lower ventricular rate. During the asynchronouspacing mode, the A4 event may occur at varying times during theventricular cycle. Control circuit 206 may set a nominal or default A4window at block 504 during which the motion signal peak amplitude isdetected for characterizing the motion signal. In one example, for apacing rate of 50 pulses per minute, the A4 window may be set having astarting time at 800 to 900 ms after a delivered ventricular pacingpulse (or a sensed R-wave) and extending until the next ventricularpacing pulse (or sensed R-wave).

In other examples, the end of the A3 window and start of the A4 windowmay be set to a percentage of the ventricular rate interval. Forexample, control circuit 206 may determine the ventricular cycle length,which may be paced or sensed, for a specified number of the most recentventricular cycles. Control circuit 206 may determine a mean or medianvalue of the determined ventricular cycle lengths and set the A4 windowto start at a percentage of the mean or median. In one example, themedian ventricular cycle length of the eight most recent ventricularcycles is determined and the A3 window is set to end and the A4 windowis set to start at 80% of the median ventricular cycle length or the4^(th) longest ventricular cycle length out of the 8 ventricular cycles.The end of the A3 window and start of the A4 window may be set between aspecified minimum and maximum time interval, e.g., not less than 650 msand not more than 900 ms in some examples. When the specified percentageof the median ventricular cycle length falls outside the limited range,the minimum or maximum value may be used.

In some examples, setting the A4 window at block 504 may be performed bysetting a long post-ventricular atrial blanking period starting from theventricular pacing pulse. The A4 window extends from the end of the longpost-ventricular atrial blanking period until the next ventricularpacing pulse. The post-ventricular atrial blanking period may be set toan extended time interval that is expected to encompass each of the A1,A2 and A3 ventricular events of the motion sensor signal, which areexpected to occur at relatively predictable intervals following theventricular pacing pulse (as shown in FIG. 5). In this way, anyrelatively large amplitude peak of the motion signal occurring after theextended atrial blanking period is more likely to be an A4 signal andless likely to be a ventricular event (A1, A2 or A3).

At block 506, control circuit 206 determines the maximum amplitude ofthe motion sensor signal during each A4 window for each motion sensorvector signal selected for analysis during the automatic sensingparameter selection process. The motion sensor vector signals selectedfor analysis may include one, two or all three single-axis vectorsignals; one, two or all three combinations of two-axis vector signals,and/or the combination of all three accelerometer axes in a three-axisvector signal. The maximum amplitude of each of the vector signals underanalysis may be determined for each ventricular cycle that occurs duringa predetermined time interval or over predetermined number ofventricular cycles. For example, the maximum amplitude may be determinedfrom each vector signal during each ventricular cycle over one minute,several minutes, one hour or more or over 50 to 1000 ventricular cycles,as examples.

Control circuit 206 determines a distribution of the maximum amplitudevalues at block 508, e.g., by populating a histogram of maximumamplitudes determined during the A4 window for each vector signalselected for analysis. For example, a histogram of maximum amplitudesmay be generated for one longitudinal vector and two radial vectors of athree dimensional accelerometer having one axis aligned with the longaxis of pacemaker 14 as described above. In other examples, a histogramof maximum amplitudes may be generated for each single-axis vectorsignal and/or each two-axis vector signal and/or the three-axis vectorsignal. When a combination of two or all three axes are used to producea vector signal, the acceleration signal sample points of the two or allthree axis signals may be summed to produce a two- or three-axis vectorsignal. In other examples, the resultant vector signal may be determinedusing vector math. The maximum amplitude may be determined fromrectified vector signals or may be a maximum peak-to-peak amplitude ofthe non-rectified vector signals.

FIG. 8 depicts two example histograms 600 and 620 generated for twodifferent motion sensor vector signals. The maximum amplitude of thevector signal detected during the A4 window is plotted along thehorizontal axis 604 of each histogram 600 and 620. The horizontal axis604 is shown in ADC units, where each ADC unit is 11.8 milli-g(acceleration of gravity), in the example shown. The histograms ofamplitudes determined from the motion sensor vector signal received bythe control circuit 206 from an ADC included in motion sensor 212 may begenerated in ADC units, but may optionally be converted to units ofacceleration, e.g., meter/second squared (m/s²), for display on anexternal device, e.g., external device 20. For example, the accelerationconversion ratio may be 1 m/s² per 100 milli-g.

The maximum amplitude during each A4 window is matched to a histogrambin value or range. The matching histogram bin count is increased by onefor each matching maximum amplitude value to track the frequency ofoccurrence of each maximum amplitude value or range. The frequency orcount of binned maximum amplitude values obtained over the predeterminedtime interval for the given vector signal is plotted along the y-axis602 in each histogram. Since the ventricular cycles are asynchronouswith the atrial rhythm, numerous ventricular cycles may occur duringwhich no true A4 event occurs during the A4 window. Thus, relativelyhigh counts 612 and 622 of relatively low maximum amplitudes may occurwhen atrial systole does not happen to coincide with the nominal A4window. A low maximum amplitude may be defined as a maximum amplitudedetected during the A4 window that is less than 5 ADC units in thisexample. The high frequency of A4 windows having a relatively lowmaximum amplitude of the vector signal reflects the relatively largenumber of ventricular cycles during which atrial systole does not happento coincide with the A4 window.

A reliable sensing vector signal includes relatively high counts 614 atrelatively high maximum amplitude values, e.g., in the range of 7 to 15ADC units, as shown in the example histogram 600. The moderately highfrequency (counts 614) of high maximum amplitude (e.g., 8 ADC units ormore) during the A4 window indicates the occurrence of A4 signals thathappen to coincide with the A4 window during the non-atrial trackingpacing mode. Since these A4 signals have a relatively high amplitude,the vector signal used to generate histogram 600 may be a highlyreliable vector signal for sensing atrial events.

In comparison, the example histogram 620 shows a relatively low or zerocount 624 of relatively high maximum amplitude signals during the A4window. The vector signal used to produce histogram 620 is considered tobe unreliable for use in detecting atrial events since most or all ofthe maximum amplitudes during the A4 window are relatively low, e.g.,within the range of the baseline noise of the vector signal. This meansthat even on cycles that the A4 signal coincides with the A4 window, theA4 amplitude is substantially in the range of the baseline noise of thevector signal, e.g., less than 5 ADC units. The orientation of the axisor axes used to produce the vector signal associated with histogram 620may result in a null signal during atrial systole.

Referring again to FIG. 7 with continued reference to FIG. 8, at block510, the histogram bins corresponding to relatively low maximumamplitudes may be rejected as being low level noise in the vectorsignal. In the example of FIG. 8, histogram bins storing counts ofmaximum amplitudes that are less than a noise threshold 606, e.g., 5 ADCunits, may be discarded as noise. The noise threshold 606 may be set toa value greater than or less than 5 ADC units in other examples and maybe set according to the baseline noise of the vector signal. In someexamples, the noise threshold 606 is optional or the noise threshold maybe set to zero.

At block 512, control circuit 206 may determine whether the maximumamplitudes meet vector selection criteria for each vector signal tested.In one example, the total number of maximum amplitudes that are greaterthan the noise threshold 606 (e.g., all maximum amplitudes counted overthe range 616 and 626 in histograms 600 and 620, respectively), isdetermined by control circuit 206 at block 512. The number of highmaximum amplitudes that are greater than a high amplitude threshold 608is also determined at block 512 by control circuit 206. The highamplitude threshold 608 is set to 8 ADC units in the example shown. Thenumber of maximum amplitudes greater than 8 ADC units is determined asthe high maximum amplitude count. The ratio of the high maximumamplitude count to the count of all maximum amplitudes greater than thenoise threshold 606 is determined at block 512 as the high maximumamplitude ratio. This high maximum amplitude ratio may be determined foreach of the tested A4 sensing vector signals and is an indication of thefrequency of high amplitude signals (as generally depicted by 614 inFIG. 8) that occur during the A4 window and are highly likely to beactual A4 signals since they are occurring outside the post-ventricularatrial blanking period.

Control circuit 206 may compare this high maximum amplitude ratio of thenumber of high maximum amplitudes (greater than threshold 608) to thenumber of all maximum amplitudes greater than the noise threshold 606determined for each single-axis vector signal that is analyzed to asingle-axis vector selection threshold at block 514. In one example, ifat least 50% of the maximum amplitude values are greater than the highamplitude threshold, after rejecting the low maximum amplitude valuesthat are less than the noise threshold, the single-axis vector signalmay be selected as the A4 sensing vector and may be used as asingle-axis vector signal for reliable A4 sensing. In the examplehistogram 600 of FIG. 8, more than 50% of the maximum amplitudesacquired over the range 616 (greater than 4 ADC units) are greater than8 ADC units, the high amplitude threshold 608. As such, when this vectorsignal is a single-axis vector signal that was used to obtain themaximum amplitude data for generating histogram 600, this single-axisvector signal may be selected as the A4 event sensing vector signal atblock 516. Use of a single-axis sensing vector signal for sensing A4events allows a single axis of the accelerometer to be powered forgenerating the A4 sensing vector signal, which saves power and mayextend the functional life of pacemaker 14 compared to using acombination of two or more axes for generating a vector signal forsensing atrial events.

In instances where two or more single-axis vector signals meet thecriteria applied at block 514, the single-axis vector signal having thehighest high maximum amplitude ratio may be selected as a single-axis A4sensing vector signal at block 516. In general, control circuit 206 mayselect a vector signal that produces a distribution of the maximumamplitudes during the A4 window that is skewed right (with adistribution tail longer on the right than on the left when amplitude isincreasing from left to right on the x-axis). A vector signal having agreatest median maximum amplitude, a highest rightward skew of themaximum amplitude distribution, or other metric indicting a rightwardskew of the maximum amplitude distribution may be selected as the solevector signal at block 516 to be used for sensing A4 events during anatrial tracking ventricular pacing mode.

In some examples, the maximum amplitudes determined for each vectorsignal may be compared to rejection criteria. When the maximumamplitudes for all vector signals meet rejection criteria, an alert maybe generated. For instance, if the high maximum amplitude ratio (theratio of the number of maximum amplitudes that are greater than the highamplitude threshold 608 to the number of maximum amplitudes greater thanthe noise threshold 606) is less than a rejection threshold, asdetermined at block 518, control circuit 206 may select a combination ofall three axis signals for producing the A4 sensing vector signal atblock 522 or select the best combination of two out of the three axissignals for generating a two-axis vector signal for A4 sensing.Selecting the minimum number of accelerometer axes required to sense A4events may conserve current demand from power source 214. Additionallyor alternatively, an alert may be generated to notify the clinician thatnone of the vector signals analyzed have met criteria for reliable A4sensing. The notification may be transmitted by telemetry circuit 208 toexternal device 20 at block 522.

In some instances, all three single-axis vector signals may have a highmaximum amplitude ratio that is less than the single-axis vector signalthreshold (“no” branch of block 514), but at least one, two or all threesingle-axis vector signals may have a high maximum amplitude ratio thatis greater than the rejection threshold (“no” branch of block 518). Whenat least one out of the possible single-axis vector signals has a highmaximum amplitude ratio that is between the single-axis vector thresholdand the rejection threshold, control circuit 206 may select two axissignals (corresponding to two different motion sensor axes) at block 520to be used in combination for A4 event sensing. The two single-axisvector signals having the highest high maximum amplitude ratios may beselected to be used in combination in a vector signal for sensing atrialevents. These two single-axis vector signals may be summed to produce atwo-axis vector signal. In some examples, the single-axis vector signalthat is aligned with the longitudinal axis of the housing 150 ofpacemaker 14 is selected with one other vector, e.g., a radial vector.The atrial event sensing vector may be selected as a combination of thelongitudinal single-axis vector signal summed with one of the radialsingle-axis vector signals having the highest high maximum amplituderatio determined at block 512 to produce a two-axis vector signal for A4event sensing.

When two (or three) single-axis vector signals are selected incombination as the A4 event sensing vector signal the multi-axis vectorsignal may be determined by vector summation of the two (or three)individual vector signals. The vector signals may be summed digitallyusing the digitized, rectified vector signals. Summation may beperformed after rectification to avoid destructive summation of two ormore vector signals. In other examples, two or three individual analogvector signals may be summed when a single-axis vector signal does notproduce a high maximum amplitude ratio greater than the single-axisvector threshold.

In other examples, instead of determining a ratio as indicated t block512, another metric of the distribution of maximum amplitudes may bedetermined and compared to vector selection and/or rejection criteria.For example, as described below in conjunction with FIG. 15, the median,mean or a specified percentile of all maximum amplitudes determined atblock 506 may be determined (after discarding maximum amplitudes lessthan a noise threshold in some examples). The median of the maximumamplitudes (or other metric of the distributions) determined for each ofthe vector signals being analyzed may be compared to each other, and thevector signal producing the greatest median maximum amplitude may beselected. In some examples, a single-axis vector signal may be selectedwhen it corresponds to the greatest median maximum amplitude. However, avector signal that is a combination of at least two axis signals willgenerally have a greater median maximum amplitude than a single-axisvector signal (due to the summation of two single-axis signals). Assuch, in some examples, a two-axis vector signal that has the greatestmedian maximum amplitude may be selected as the atrial event sensingvector signal.

In instances where each of the two-axis vector signals are rejected dueto the maximum amplitudes meeting rejection criteria, the combination ofall three motion sensor axis signals may be selected as a three-axisvector signal for atrial event sensing. As further described inconjunction with FIG. 15, a two-axis vector signal (or any analyzedvector signal) may be rejected when fewer than a threshold count of themaximum amplitudes acquired for the given vector signal are greater thana minimum amplitude threshold. The minimum amplitude threshold may beset to the minimum available A4 sensing threshold amplitude in someexamples.

FIG. 9 is a flow chart 700 of a method for establishing an ending timeof the A3 window (e.g., ending time 422 of window 424 shown in FIG. 5).At block 702, control circuit 206 sets the pacing mode to the non-atrialtracking pacing mode. The pacing rate may be set to a nominal pacingrate, e.g., 50 pulses per minute, by setting the VV pacing interval. Atblock 704, the A4 sensing vector (a single-axis vector signal or asummation of two or more single-axis vector signals) is selected.Control circuit 206 may select the vector signal established as the A4sensing vector in the process described above in conjunction with FIGS.7 and 8. The process of flow chart 700 may be performed only for aselected atrial event sensing vector signal (a single-axis vector or atwo-axis or three-axis vector signal from the summed combination of twoor more single-axis vector signals) and may be repeated if the A4sensing vector signal selection is changed. In other examples, at leastportions of the process of flow chart 700 may be performed for allavailable motion sensor vector signals or multiple selected vectorsignals to enable simultaneous motion sensor signal data acquisition foruse in generating distributions of motion sensor signal features.

In some examples, the non-atrial tracking pacing mode and rate are stillin effect after selecting the atrial event sensing vector at block 520of FIG. 7. Control circuit 206 may advance directly to the process offlow chart 700 for establishing the A3 window ending time, e.g.,directly from block 520 of FIG. 7 to block 706 of FIG. 9. In examplesthat include a one-dimensional, single-axis motion sensor or a fixed A4sensing vector signal selection, the vector selection process of FIG. 7is unnecessary. The process of establishing the A3 window ending timeaccording to flow chart 700 may be performed without performing theprocess of flow chart 500 first by selecting a manually programmed ordefault atrial event sensing vector signal at block 704.

A nominal A3 window is set at block 706, e.g., beginning 600 ms after aventricular event, sensed or paced, and extending until the nextventricular event. The nominal A3 window may be set by setting apost-ventricular atrial blanking period extending from a ventricularelectrical event, sensed or paced, for a predetermined time interval,e.g., 600 ms. The nominal A3 window may be set to begin after anexpected time of the A1 and A2 signals (e.g., as shown in FIG. 4) andextend as late as the next ventricular electrical event to increase thelikelihood of capturing A3 signals during the nominal A3 window. In someexamples, the A3 window is set at block 706 to start at a fixedinterval, e.g., 600 ms after a ventricular event (sensed R-wave orventricular pacing pulse) and extend to an A3 window ending time set toa percentage, e.g., 80%, of a mean or median ventricular cycle lengthdetermined from a specified number of recent ventricular cycle lengths,e.g., the 8 ventricular cycle lengths.

At block 708, control circuit 206 sets a nominal threshold amplitude.The nominal threshold amplitude may be 9 ADC units, which may correspondto 0.9 m/s², as one example. The timing of the latest crossing of thenominal threshold amplitude in each A3 window is determined at block 709over a predetermined time period or number of ventricular cycles foreach vector signal under analysis. When atrial systole (and the A4event) does not happen to occur during the A3 window, the latestthreshold crossing may be a true A3 signal and is expected to occurrelatively early in the nominal A3 window since A3 signals areventricular event signals that follow the ventricular electrical eventat a relatively consistent time interval. When atrial systole doeshappen to occur during the A3 window, the latest threshold crossingcould be an A3 or an A4 signal, depending on when atrial systole occursduring the A3 window. Relatively late threshold crossings during anextended A3 window, however, are much more likely to be an A4 signalthan an A3 signal, since the A3 signal is generally tied to the timingof the ventricular electrical event. In some ventricular cycles, themotion sensor vector signal may cross the nominal threshold amplitudemore than once during the A3 window. For example, the true A3 signal andthe true A4 signal may cross the nominal threshold amplitude. In thiscase, the timing of only the latest threshold crossing is stored in someexamples.

When the threshold amplitude crossings are accumulated over a largenumber of ventricular cycles, e.g., over at least 50 to 100 ventricularcycles or more, a relatively high frequency of the latest thresholdcrossings will represent A3 signals and some will represent A4 signalswhen atrial systole happens to occur during the A3 window. In someinstances, fused A3/A4 events may occur during the A3 window as thelatest threshold amplitude crossing. A relatively late thresholdamplitude crossing could be an A1 signal in some instances, although A1and A2 signals are likely to occur during the post-ventricular atrialblanking period. A distribution of the timing of the latest thresholdamplitude crossings may reveal an expected time of A3 events and anexpected time of A4 events during the ventricular cycle.

The data accumulated at block 709 may be used to populate a histogram atblock 710. The latest nominal threshold amplitude crossing timesaccumulated beat-by-beat over the predetermined time interval or numberof ventricular cycles may be binned according to histogram bin timeinterval ranges. A count of the number of latest threshold crossingsoccurring during each bin time interval range is determined.

FIG. 10 is an example of a histogram 750 of the latest nominal thresholdamplitude crossing times that may be generated at block 710 of FIG. 9for one sensing vector signal. The latest threshold crossing time isplotted along the x-axis 754 in units of milliseconds (ms) andrepresents the time after the ventricular electrical event that the lastnominal threshold amplitude crossing occurred during a ventricularcycle. The frequency or count of latest threshold crossing times isplotted along the y-axis 752. In the example shown the left-most, lowestbin includes the latest crossing times occurring in the range of 601 msto 650 ms after the ventricular electrical event for an A3 window havinga starting time 756 at 600 ms after the ventricular electrical event.The right-most bin includes the latest crossing times occurring in therange of 1001 to 1050 ms after the ventricular electrical event (pacingpulse or sensed R-wave). Each bin includes a time range of 50 ms in thisexample, and the A3 window extends from 600 ms after the precedingventricular electrical event to the next ventricular electrical event.Other starting and/or ending times for the A3 window may be selected(and may depend on the ventricular rate), and other time ranges for thehistogram bins may be used in other examples.

The distribution represented by histogram 750 presents a bimodaldistribution having a left peak 772 corresponding to probable A3 signalsduring the extended A3 window and a right peak 770 corresponding toprobable A4 signals during the extended A3 window. An A4 confidence timethreshold 758 may be set as a time after which the nominal thresholdamplitude crossings are expected to be A4 signals with a highprobability and highly unlikely to be A3 signals. In the example of FIG.10, the A4 confidence time threshold 758 is set to 900 ms based on theventricular pacing rate being set to 50 pulses per minute. The A4confidence time threshold 758 may be set to a fixed value based on theventricular rate during the accumulation of the latest thresholdcrossing times. In other examples, the A4 confidence time threshold 758may be set based on a predetermined percentage, e.g., a predeterminedpercentile, of all of the accumulated latest threshold crossing times.

The leftmost peak of the bimodal distribution is represented by thehighest bin count 772 over the remaining range 760 of histogram binsafter discarding bins higher than the A4 confidence time threshold 758.The leftmost peak 772 likely represents the occurrence of A3 eventsduring the extended A3 window and may include some fused A3/A4 signals.An appropriate ending time for the A3 window may be any time from themedian value 762 of the latest threshold crossing times over the range760 up to the A4 confidence time threshold 758. An A3 window ending timemay be selected between the median 762 and the A4 confidence timethreshold 758 so that the A3 window includes A3 signals (and fused A3/A4signals) with a high probability. In some examples, the A3 window endingtime, or the A4 window starting time, used for A4 sensing during theatrial tracking ventricular pacing mode may be set to a time based onthe left peak of the bimodal distribution of the latest nominalthreshold crossing times. For instance, the A3 window ending time usedduring an atrial tracking ventricular pacing mode may be set to the leftpeak (when time is increasing from left to right) of the bimodaldistribution plus an offset, where the offset is a predetermined valueranging from zero to 200 ms as examples.

Returning to FIG. 9, the counts in the populated histogram bins greaterthan the A4 confidence time threshold are discarded at block 712. Atblock 714, control circuit 206 selects the A3 window ending time basedon the remaining histogram bin data after discarding the bins greaterthan the A4 confidence time threshold. Control circuit 206 may determinethe median time of the latest nominal amplitude threshold crossing ofthe remaining bins. The A3 window ending time may be established as themedian of the distribution plus an offset. The offset may be apredetermined value ranging from 0 ms to 200 ms, e.g., 50 ms to 100 ms.In other examples, the A3 window ending time may be set to a percentileof the remaining histogram bin counts (over range 760 in FIG. 10) afterdiscarding histogram bins greater than the A4 confidence time threshold.For instance, after discarding the bin counts greater than the A4confidence time threshold 758, the A3 window ending time may be set tothe time at which at least 70%, 80%, 90%, or 95% of the latest thresholdcrossing times are less than the A3 ending time.

In the example of FIG. 10, the A3 window starts at the expiration of apost-atrial ventricular blanking period, e.g., 600 ms after aventricular event, until the next ventricular event (pacing pulse orsensed R-wave). During this extended A3 window, both early and latethreshold crossings are detected, resulting in the bimodal distributionshown in FIG. 10 which includes a left peak 772 corresponding to likelyA3 event signals and a right peak 770 corresponding to likely A4 eventsignals. Rather than setting an extended A3 window then discarding thebins greater than the A4 confidence time threshold, the A3 window may beset at block 706 to extend from 600 ms (or the end of thepost-ventricular atrial blanking interval) until the A4 confidence timethreshold 758, which may be set to a percentage of the medianventricular cycle length as described above. For instance, the A3 windowmay be set to extend from 600 ms until 80% of the median of eightventricular cycle lengths, and not less than 650 ms or greater than 900ms when the pacing lower rate is set to 50 pulses per minute. In thisway, the latest threshold crossings during the A3 window are most likelyA3 events since they occur before the A4 confidence time threshold 758.The histogram bins corresponding to even later threshold crossings,after the A4 confidence time threshold 758, need not be populated sincethey are unlikely to contain true A3 event threshold crossing times. TheA3 window ending time may be established as the median of thedistribution of latest threshold crossing times plus an offset.

FIG. 11 is a flow chart 800 of a method for establishing early and latevalues for the A4 sensing threshold to be applied during the A3 windowand after the A3 window, respectfully, e.g. for sensing A4 signalsduring an atrial-tracking ventricular pacing mode. At block 802, controlcircuit 206 sets the pacing mode to the non-atrial tracking pacing modeand sets the VV pacing interval according to a selected pacing rate,e.g., 50 pulses per minute. At block 804, control circuit 206 selectsthe A4 sensing vector (as a single-axis vector signal or combination oftwo or more acceleration axis signals), e.g., based on the method ofFIG. 7.

In some examples, the process of flow chart 800 is performed using onlythe A4 sensing vector signal selected by the method of FIG. 7. In otherexamples, portions of the process of flow chart 800 may be performed forall available motion sensor vector signals, including single-axis,two-axis and three-axis vector signals, or any number of vector signalsselected to be analyzed. For example, the data required to generatehistograms for setting the A4 sensing threshold amplitude values may beacquired for multiple vector signals used in the process of FIG. 7, butthe data corresponding only to the vector signal selected as the A4sensing vector signal at block 516, 520 or 522 of FIG. 7 may be used insetting the A4 sensing threshold amplitude values.

The A3 window ending time may be set at block 806. In one example, theA3 window ending time is set to a percentage of a median ventricularcycle length as described above. In other examples, the A3 window is setto the A3 window ending time selected at block 714 of FIG. 9, based onthe histogram of the latest threshold crossing times. The A3 window mayextend from a fixed starting time, which may be programmable or based onempirical data, to the A3 window ending time that is automaticallydetermined from a distribution of latest nominal threshold amplitudecrossing times as described above in conjunction with FIGS. 9 and 10. Inother examples, a manually programmed or default A4 sensing vectorsignal and/or A3 window ending time are set at blocks 804 and 806,respectfully. In this case, the processes of FIGS. 7 and 9 are notnecessarily performed prior to the process of FIG. 11 for establishingA4 sensing threshold amplitude values.

At block 808, control circuit 206 determines the maximum amplitude ofthe motion signal during the A3 window for each ventricular cycle over apredetermined number of cycles or predetermined time interval. Controlcircuit 206 determines the maximum amplitude of the motion signal afterthe A3 window ending time and before the next ventricular electricalevent (e.g., during the A4 window) at block 810, for each ventricularcycle over the predetermined number of cycles or predetermined timeinterval.

The maximum amplitudes determined during the A3 windows are used bycontrol circuit 206 to generate an A3 window maximum amplitudedistribution, for example by populating an A3 window maximum amplitudehistogram, at block 812. The counts of histogram bins corresponding tomaximum amplitudes less than a noise threshold may be discarded at block814. A very low maximum amplitude during the A3 window may not berepresentative of a true A3 or A4 event and may be baseline noise of themotion signal. At block 816, control circuit 206 selects an early A4sensing threshold amplitude value to be applied during the A3 sensingwindow based on the remaining, non-discarded histogram data. Methods forselecting the early A4 sensing threshold amplitude value based on the A3window histogram data are described below in conjunction with FIG. 12.

Control circuit 206 may generate a distribution of the A4 window maximumamplitude data, e.g., by populating an A4 window maximum amplitudehistogram, at block 818 using the maximum amplitudes determined at block810 during the A4 window (after the A3 window until the end of theventricular cycle marked by the next ventricular electrical event).Histogram bins storing maximum amplitudes that are less than a noisethreshold are discarded at block 820. Control circuit 206 selects a lateA4 sensing threshold amplitude value based on the remaining(non-discarded) distribution of maximum amplitude values at block 822.Methods for selecting the late A4 sensing threshold amplitude valuebased on the histogram data are described below in conjunction with FIG.13.

FIG. 12 is one example of a histogram 850 of maximum amplitudes of amotion sensor vector signal during A3 windows that may be generated bycontrol circuit 206. The maximum vector signal amplitude is plotted onthe x-axis 856 (in ADC units in this example). The counts of eachhistogram bin are plotted along the y-axis 854. Each histogram bin isshown to include an amplitude range of one ADC unit in FIG. 12 thoughother histogram bin resolutions may be used (and may be arranged inunits of g or m/s²). Each bin stores the count of how many times themaximum amplitude of the vector signal during the A3 window falls in therespective bin range.

A noise threshold amplitude 858 may be a predefined value or determinedas a percentile of the histogram frequency distribution. Maximumamplitudes during the A3 window that are less than the noise thresholdamplitude 858 may be attributed to baseline noise during the A3 window(or very low amplitude A3 signals). The histogram bins corresponding tomaximum amplitudes that are less than the noise threshold amplitude 858may be discarded for the purposes of selecting an early A4 sensingthreshold amplitude, also referred to herein as an “early atrial eventsensing threshold.” In the example of FIG. 12, the noise threshold maybe 4 ADC units, or about 50 milli-g or about 0.5 m/s².

After discarding the histogram bins that are less than (to the left of)the noise threshold amplitude 858, control circuit 206 may determine theearly A4 sensing threshold value 860 as a percentile of the remainingdistribution of maximum amplitudes determined during the A3 windows.Since most of the maximum amplitude values determined during the A3windows and counted in the histogram 850 are expected to representactual A3 events, a majority of the maximum amplitudes should be lessthan the early A4 sensing threshold value 860 so that they are notfalsely detected as A4 events.

A smaller percentage of the relatively high maximum amplitudes occurringduring the A3 window, e.g., those greater than the early A4 sensingthreshold value 860 may represent fused A3/A4 events, which should besensed as A4 events. The early A4 sensing threshold value 860 may be setto a relatively high percentile, e.g., the eightieth, eighty-fifth, orninetieth percentile of the remaining (non-discarded) maximum amplitudesof histogram 850 according to one example. In one example, the upper 15%of the maximum amplitude signals during the A3 window (after discardingbins below the noise threshold) would meet atrial event sensing criteriaand would be sensed as A4 signals, e.g., during an atrial trackingpacing mode. The lower 85% of the maximum amplitude signals during theA3 window would not be sensed as A4 signals.

FIG. 13 is one example of an A4 window maximum amplitude histogram 870that may be produced by control circuit 206 at block 818 of FIG. 11 forone vector signal being analyzed. The maximum amplitude during the A4window of the vector signal being analyzed is plotted on the x-axis 876.The counts of each histogram bin are plotted along the y-axis 874. Eachhistogram bin is shown to include a range of one ADC unit in FIG. 13though other histogram bin resolutions may be used. Each bin stores thecount of how many times the maximum amplitude of the vector signal afterthe A3 window (during the A4 window) falls in the respective bin range.

A noise threshold amplitude 878 may be a predefined value or determinedas a percentile of the histogram frequency distribution. The histogrambin counts less than the noise threshold amplitude 878 may be discardedfor the purposes of selecting a late A4 sensing threshold amplitudevalue. These relatively low maximum amplitude signals during the A4window are likely baseline noise and not true A4 signals. In the exampleof FIG. 13, the noise threshold is 5 ADC units (or about 0.6 m/s²).Counts in bins less than 5 ADC units are discarded for the purposes ofselecting a late A4 sensing threshold amplitude value, also referred toherein as a “late atrial event sensing threshold.”

After discarding the histogram bins corresponding to maximum amplitudesthat are less than the noise threshold amplitude 878, control circuit206 may determine the late A4 sensing threshold amplitude value 880 as apercentile of the remaining maximum amplitude distribution. Since mostof the maximum amplitude values determined during the A4 window andcounted in the histogram 870 are expected to represent actual A4signals, a majority of the maximum amplitudes should be greater than thelate A4 sensing threshold value 880 to avoid undersensing of the A4events. A smaller percentage of the maximum amplitudes occurring duringthe A4 window may be noise or even late A3 signals. The late A4 sensingthreshold value 880 may be set to a relatively low percentile of theremaining (non-discarded) maximum amplitudes of histogram 870, e.g., thefifth percentile. In this way, after discarding maximum amplitudes lessthan the noise threshold 878, the lower 5% of the remaining maximumamplitude signals during the A4 window would not be sensed, but 95% ofthe maximum amplitude signals would be greater than the late A4 sensingthreshold value 880 and meet atrial event sensing criteria, e.g., duringan atrial tracking ventricular pacing mode. The example percentiles andnoise thresholds given here are illustrative in nature and it is to beunderstood that other percentiles and noise thresholds may be used toestablish the early and late A4 sensing threshold values.

The histograms generally depicted in the drawings presented herein, orother types of graphical representations, of the distributions of motionsensor signal features determined for use in setting atrial eventsensing parameters may be generated for display on display unit 54 ofexternal device 20. The generated display may include the value or agraphical depiction (e.g., a line, bar or icon overlaid on thehistogram) to indicate the atrial event sensing parameter value orsetting determined by control circuit 206 (or external processor 52)based on the distribution of the determined features.

FIG. 14 is a flow chart 900 of a method for controllingatrial-synchronized ventricular pacing according to one example. Atblock 902, control circuit 206 selects an A4 sensing vector. The A4sensing vector (a single-axis vector signal, two-axis vector signal orthree-axis vector signal) may be selected using the methods describedabove in conjunction with FIGS. 7 and 8. At block 904, the A3 window isset according to a starting time and an ending time. The ending time maybe set to a time following a preceding ventricular electrical event thatis determined using the method described above in conjunction with FIGS.9 and 10. At block 906, the multi-level A4 sensing threshold is set byestablishing the early A4 sensing threshold amplitude value and the lateA4 sensing threshold amplitude value using the methods described inconjunction with FIGS. 11-13.

At least one of the atrial sensing parameters out of the A4 sensingvector, A3 window ending time, early A4 sensing threshold amplitudevalue and/or late A4 sensing threshold amplitude value is established bydetermining features of the motion sensor signal, generating at leastone histogram or other representation(s) of the distribution ofdetermined feature(s) of the motion sensor signal and selecting therespective A4 sensing parameter based on an analysis of thedistribution. In some examples, one or more of the atrial event sensingparameters including the A4 sensing vector, A3 window ending time andearly and late A4 sensing threshold values may be set to a default oruser programmable value without generating a histogram or otherrepresentative distribution of motion signal features.

In some examples, the A4 sensing vector is determined first as shown byblock 902. After the A4 sensing vector is selected, an A3 window endingtime may be established (block 904), followed by the early and late A4sensing threshold amplitude values (block 906). In other examples,however, A4 sensing parameters may be determined in a different sequencethan that shown in FIG. 14 or determined partially or whollyconcurrently. For instance, a nominal A3 window ending time of 800 to900 ms may be set while pacing in a non-atrial tracking pacing mode toenable data acquisition simultaneously during multiple ventricularpacing cycles for generating distributions of motion sensor signal datafor establishing two or more atrial event sensing parameterssimultaneously. The maximum amplitude during the A3 window, the maximumamplitude after the A3 window, and the latest nominal threshold crossingoccurring after the start of the A3 window (e.g. after 600 ms) may bedetermined from each ventricular cycle for generating distributions suchas the histograms shown in the accompanying drawings. The A4 sensingvector, A3 window ending time, and early and late values of the atrialevent sensing threshold values may be established based on concurrentlyacquired motion sensor signal features and respective distributionsgenerated therefrom.

At block 908, control circuit 206 may set the pacing mode to an atrialtracking ventricular pacing mode such as a VDD pacing mode. At block910, atrial event detector circuit 240 senses an A4 event during aventricular cycle using the A4 sensing parameters established at blocks902 through 906. Control circuit 206 may generate an atrial sensed eventsignal in response to the atrial event detector circuit 240 sensing theA4 event. The atrial sensed event signal may be used for controlling thetiming of ventricular pacing pulses during the VDD pacing mode. Theatrial tracking ventricular pacing mode that is set at block 908 may bereferred to as an atrial synchronized ventricular pacing mode because anAV pacing interval may be started (block 912) in response to sensing anA4 signal (block 910) for controlling the timing of ventricular pacingpulses. If an R-wave is sensed before the AV interval expires (“yes”branch of block 918), control circuit 206 senses the next A4 signal atblock 910. An A4 signal is sensed in response to the earliest crossingof the multi-level atrial event sensing threshold during the A3 windowor the A4 window.

Upon expiration of the AV pacing interval (“yes” branch of block 914), aventricular pacing pulse is generated by the pulse generator 202 anddelivered (block 920). In this way, the ventricular pacing pulses aresynchronized to atrial systolic events to provide a more normal heartrhythm in a patient experiencing AV conduction block.

FIG. 15 is a flow chart 1000 of a process performed by pacemaker 14 forsetting atrial event sensing parameters according to another example.The automatic selection of starting values for atrial event sensingparameters may be initiated by control circuit 206 at block 1001 after atime delay following a telemetry session with external device 20 in someexamples. For instance, the feature of automatic selection of atrialevent sensing parameters may be programmed “on” or enabled by a userinteracting with external device 20 during an implant procedure or anypatient follow-up procedure, in a clinic or hospital or remotely. Thecontrol circuit 206 may detect inactivity or termination of a telemetrysession with external device 20 and initiate the automatic selectionprocess at block 1001 by waiting for a time delay, e.g., after one toten minutes or after three minutes in one example, after telemetrycommunication is no longer received by pacemaker telemetry circuit 208.This time delay after receiving of a telemetry communication signal hasstopped may allow other programming or procedures to be completed, e.g.,during an implant procedure or programming and interrogation session,before the automatic atrial event sensing parameter selection process isstarted.

Other criteria may be applied by control circuit 206 at block 1001before starting the selection process. For example, control circuit 206may verify that the patient activity level is less than a thresholdlevel, verify that a target heart rate for rate responsive pacing basedon the patient activity level is less than a threshold rate, and/orverify that the actual ventricular rate is not greater than a thresholdrate. In some examples, control circuit 206 may be configured todetermine a patient activity metric from the motion sensor signal thatis correlated to the level of patient physical activity. This patientactivity metric may be used by control circuit to control rateresponsive ventricular pacing in some examples, to provide ventricularrate support during times of increased or elevated patient activity.

Upon initiating the atrial event sensing parameter selection process,control circuit 206 may set test values of multiple control parametersto enable motion sensor signal analysis and data collection forgenerating distribution data for setting atrial event sensing controlparameters. At block 1002, control circuit 206 may switch from aprogrammed atrial tracking ventricular pacing mode, e.g., VDD pacingmode, to a temporary non-atrial tracking ventricular pacing mode, e.g.,VDI pacing mode that includes generating the motion sensor signal foranalysis. Control circuit 206 may set a temporary lower pacing rate tocontrol the ventricular pacing rate during the motion sensor signalanalysis. In one example, the lower pacing rate is set to 50 pulses perminute but may be set to 40 pulses per minute or higher in variousexamples.

At block 1002, control circuit 206 may set test values for a test A3threshold amplitude for detecting the latest motion signal thresholdcrossings during the A3 window for use in establishing the ending timeof the A3 window. Additionally or alternatively, control circuit 206 mayset one or both of the early and late A4 sensing threshold amplitudevalues to maximum possible values to avoid actual A4 sensing during themotion sensor signal analysis. In an illustrative example, the A4sensing threshold amplitude values, both early (during A3 window) andlate (during A4 window), may be set to a maximum limit of the ADC or toa value that is beyond the maximum value of the distribution range beinggenerated or the maximum bin range of the histogram being generated ofmaximum amplitudes of the vector signals being analyzed. In this way, A4event detections are avoided, which may otherwise terminate the A3 or A4windows precluding additional analysis of the motion sensor signalduring a given ventricular cycle. Control circuit 206 may further set apost ventricular blanking period, and a test setting of the ending timeof the A3 window.

As described above, the end of the A3 window (and start of the A4window) may be set to a percentage of the ventricular rate intervalduring motion sensor signal analysis. For example, control circuit 206may determine the ventricular cycle length, which may be paced orsensed, for a specified number of the ventricular cycles upon switchingto the VDI pacing mode at block 1002. Control circuit 206 may determinea mean or median value of the determined ventricular cycle lengths andset the test ending time of the A3 window to start at a percentage ofthe mean or median ventricular cycle length. In one example, the test A3window ending time is set to 80% of the fourth shortest ventricularcycle length out of the first eight ventricular cycles after switchingto the VDI pacing mode. The end of the A3 window (and start of the A4window) may be set between a specified minimum and maximum timeinterval, e.g., not less than 650 ms and not more than 900 ms from themost recent ventricular electrical event (sensed or paced) in someexamples. When the specified percentage of the median ventricular cyclelength falls outside the limited range, the minimum or maximum value maybe used instead.

The post-ventricular blanking period may be set to a fixed value, avalue based on the lower pacing rate set during the temporary VDI pacingmode, or a median ventricular cycle length. In one example, thepost-ventricular blanking period is set to 600 ms when the lower pacingrate is set to 50 pulses per minute. The A3 window starts uponexpiration of the post-ventricular blanking period and extends to thetest A3 window ending time.

The test A3 threshold amplitude for detecting the latest motion sensorsignal threshold crossing during the test A3 window, for use in settingthe A3 window ending time, e.g., as described in conjunction with FIGS.9 and 10, may be set to a relatively low amplitude that is expected tobe greater than the baseline motion sensor signal noise. For example,the test A3 threshold amplitude may be set to 9 ADC units, which maycorrespond to approximately 106 milli-g or about 1 m/s².

At block 1002, control circuit 206 may establish the vector signals frommotion sensor 212 that will be analyzed for generating distributiondata. In some examples, each available two-axis vector signal and thethree-axis vector signal are generated and analyzed to generateamplitude and timing distribution data for each of the vector signals.For example, referring to each axis of the three-dimensionalaccelerometer as axis 1, axis 2 and axis 3, a combination of axis 1 andaxis 2 may be referred to as the 1+2 vector signal, a combination ofaxis 1 and axis 3 may be referred to as the 1+3 vector signal, and thecombination of axis 2 and axis 3 may be referred to as the 2+3 vectorsignal. The combination of all three axis signals from the motion sensor212 may be referred to as the 1+2+3 vector signal. In one example, eachof the 1+2 vector signal, 1+3 vector signal, 2+3 vector signal and the1+2+3 vector signal may be processed and analyzed by control circuit 206to determine amplitude and timing data of the respective vector signalsfor selecting at least one atrial event sensing control parameter usedduring the atrial tracking ventricular pacing mode.

After setting the test pacing mode, pacing rate, test vector signals andother test control parameters, control circuit 206 may begin acquiringamplitude and timing data from the vector signals being analyzed atblock 1004. When the four vector signals listed above are selected foranalysis during the automatic atrial sensing parameter selectionprocess, each vector signal may be analyzed on a rotating basis toremove or minimize the effects of confounding factors on a particularvector signal, such as posture-dependent changes that may occur in avector signal due to changing patient position or activity. For example,one vector signal may be analyzed over a one minute time interval foracquiring amplitude and timing data then the next vector signal may beanalyzed for the next one minute time interval and so on. In this way,each of the four vector signals listed above may be analyzed over oneminute of every four minute time interval. This process may be repeateda specified number of times, e.g., two times, five times, ten times,etc., until a desired number of minutes or data points are obtained foreach of the vector signals being analyzed. In one example, amplitude andtiming data are obtained from each of the four vector signals listedabove on a rotating basis for a total of five minutes per vector signalor for at least 20 minutes total.

In other examples, one or more of the single-axis vector signals, e.g.,the axis 1 vector signal, the axis 2 vector signal and/or the axis 3vector signal may be included as test vector signals in the analysis forobtaining vector signal data at block 1004. Any specified number ofvector signals where each vector signal may be obtained from a singleaccelerometer axis, the sum of two axis signals, or the sum of all threeaccelerometer axis signals may be included in the analysis for obtainingamplitude and timing data at block 1004. The number of vector signalsanalyzed and the accelerometer axes used to obtain each vector signalmay be programmable by a user. When a combination of axes are used, thesignal from each axis of the combination of axes may be sampled atspecified time slots of a sampling rate so that the sampled points fromtwo or all three axis signals may be summed to produce the desiredvector signal that is a combination of two or all three accelerometeraxis signals. For example, if a vector signal is sampled every 1 ms,each axis signal may be sampled for 333 ms time slots so that a sampleof each axis signal is available for summing with one or more other axissignals at each 1 ms sample point time.

At block 1004, amplitude and/or timing data is accumulated from thevector signals being analyzed as needed for selecting one or more atrialevent sensing parameters. For example, one or more of the A4 sensingvector signal, the early A4 sensing threshold amplitude value, the lateA4 sensing threshold amplitude value, and/or the A3 window ending time,or any combination thereof, may be established by control circuit 206during the process of flow chart 1000. When the process of flow chart1000 is being performed to select the A4 sensing vector signal, themaximum amplitude during the A4 window is determined from each testvector signal for a desired number of ventricular cycles or time period.By setting the late A4 sensing threshold amplitude value to a relativelyhigh value, e.g., a maximum available value, the A4 window is notterminated before the next ventricular event allowing control circuit206 to determining the maximum vector signal amplitude until the nextventricular event, paced or sensed.

Other data determined from each of the vector signals may include thetime of the latest test A3 threshold crossing during the test A3 window(e.g., as generally described in conjunction with FIGS. 9 and 10) andthe maximum vector signal amplitude during the A3 window and/or the A4window (e.g., as generally described in conjunction with FIGS. 11-13).The amplitude and/or timing data determined from each test vector signaldepends on which of the atrial event sensing parameter values that arebeing set by control circuit 206 during the process of flow chart 1000.

At any time during or upon completion of the determination of theamplitude and/or timing data from the motion sensor vector signals atblock 1004, control circuit 206 may detect an abort condition asindicated by block 1006. One or more conditions may result inconfounding effects on the amplitude and timing data warranting a pauseor delay in obtaining the data. For example, high or variable patientphysical activity and/or high or variable heart rate may cause changesin the amplitude and timing data for a given vector signal thatconfounds the distribution data generated for the vector signal. Assuch, the amplitude and/or timing data acquired at block 1004 forselecting one or more atrial event sensing control parameters may beacquired over time intervals associated with a relatively low, stableheart rate, e.g., less than 80 beats per minute, and/or patient physicalactivity level, e.g., less than an activity threshold corresponding toactivities of daily living or rest.

Control circuit 206 may determine a patient physical activity metricfrom the motion sensor signal at regular time intervals. A target heartrate and sensor indicated pacing rate may be determined based on thephysical activity metric to provide rate responsive pacing to supportthe level of patient physical activity. Control circuit 206 may detectan abort condition based on at least one patient physical activitymetric or level determined from the motion sensor signal as beinggreater than a threshold activity level. In another example, controlcircuit 206 may detect an abort condition based the variability of thepatient physical activity level, e.g., by detecting a threshold changein the physical activity level within a predetermined time interval. Inother examples, control circuit 206 may detect an abort condition inresponse to determining that the target heart rate, sensor indicatedpacing rate and/or actual ventricular rate, paced or sensed, is greaterthan a threshold rate or is highly variable based on threshold ratechange within a predetermined time interval.

In one example, a ventricular rate that is faster than 85 beats perminute may be an abort condition. Control circuit 206 may determineventricular cycle lengths during the amplitude and timing dataacquisition at block 1004. After data acquisition is completed, controlcircuit 206 may determine if more than a percentage threshold, e.g.,more than 20% to 30%, of the ventricular cycle lengths are shorter thana threshold interval at block 1006. For example, if 20% or more of theventricular cycle lengths during the data acquisition were shorter thanabout 700 ms (or faster than a rate of about 85 beats per minute), thenan abort condition may be detected at block 1006 due to a highventricular rate. The data may be discarded without generating adistribution or histogram of the data. In other examples, the data maybe stored and compiled with data obtained during the next dataacquisition time for generating and analyzing a distribution of thedata.

The threshold ventricular cycle length interval for detecting a highheart rate may be 650 to 750 ms in other examples. In still otherexamples, the threshold ventricular cycle length interval may be setbased on a mean or median ventricular cycle length determined from theventricular cycle lengths stored during the data acquisition. Forinstance, the threshold cycle length may be set to the medianventricular cycle length minus 100 to 150 ms or set to correspond to aventricular rate that is 10 to 20 beats per minute faster than themedian ventricular rate during data acquisition. In an illustrativeexample, when more than 20% (or other selected percentage) of theventricular cycle lengths correspond to a ventricular rate that isfaster than the rate of the median cycle length during the dataacquisition plus 10 beats per minute, an abort condition may be detectedat block 1006 due to a variable or high ventricular rate.

An abort condition may be detected at block 1006 due to a variable heartrate that includes a threshold percentage of ventricular cycle lengthslonger than a long threshold cycle length (or slower than acorresponding ventricular rate) in some examples. Control circuit 206may set a long threshold cycle length based on the ventricular ratecorresponding to the median ventricular cycle length determined fromventricular cycle lengths stored during the data acquisition of block1004. For example, the long threshold cycle length may be set to theventricular rate interval corresponding to the median ventricular ratedetermined from the median ventricular cycle length during dataacquisition minus 10 beats per minute. When more than the thresholdpercentage (e.g., 20%, 30% or other percentage) of ventricular cyclelengths are longer than a slow ventricular rate interval, e.g.,corresponding to 10 beats per minute less than the median rate, an abortcondition may be detected due to a variable ventricular rate at block1006.

Additionally or alternatively, a high or variable patient activity levelmay be an abort condition detected at block 1006. A patient physicalactivity metric may be determined by integrating the absolute value of aselected accelerometer vector signal over a predetermined time duration(such as 2 seconds). This metric may be referred to as an “activitycount” and is correlated to the acceleration imposed on the motionsensor due to patient body motion associated with physical activityduring the predetermined time interval. The 2-second (or other timeinterval) activity count can be used directly to indicate patientphysical activity level in some examples or combined in furthercalculations to obtain other physical activity metrics. At least oneactivity count may be compared to a threshold count at block 1006 todetermine if an abort condition is met. In some examples, a thresholdnumber of activity counts, e.g., 10 to 40 activity counts, greater thana threshold activity count may be detected as an abort condition. Forinstance, when 30 activity counts, each determined over 2-secondintervals, are greater than a threshold activity count during the dataacquisition, control circuit 206 may determine that an abort conditionis met at block 1006 due to high patient activity. The activity countthreshold may correspond to a patient activity that exceeds activitiesof daily living, corresponds to brisk walking or other activity levelthat may be associated with body motion and/or posture changes that mayalter the motion sensor signal compared to relatively lower physicalactivity, e.g., rest or low level activities of daily living.

In other examples, each activity count may be compared to a medianactivity count, and if more than a threshold percentage of each activitycount determined during data acquisition differs from the medianactivity count by more than a threshold difference (plus or minus), anabort condition may be detected due to variable patient activity atblock 1006. In still other examples, a target heart rate or sensorindicated pacing rate may be determined by control circuit 206 based onthe activity counts. A target heart rate or sensor indicated pacing ratedetermined based on a patient physical activity metric may be comparedto a threshold rate, e.g., 10 beats per minute greater than the currentventricular rate, and/or rate variability criteria for detecting anabort condition in some examples.

In addition or alternatively to heart rate and/or patient physicalactivity based abort conditions, control circuit 206 may detect an abortcondition in response to telemetry circuit 208 receiving communicationsignals, e.g., from external device 20. When a telemetry session isinitiated and programming commands are being received by telemetrycircuit 208, for instance, control circuit 206 may detect an abortcondition. In some examples, telemetry circuit 208 may be enabled totransmit the motion sensor signal or related data during the atrialevent sensing parameter set-up procedure of flow chart 1000; howeverother telemetry signals received from external device 20, such asprogramming commands, may be detected as an abort condition. Aprogramming command includes an instruction to change a programmablecontrol parameter used by control circuit 206 in controlling sensing,therapy delivery or other pacemaker functions.

When an abort condition is detected at block 1006, control circuit 206may determine if a maximum time period for data acquisition and atrialevent sensing parameter selection has been reached at block 1010. Ifnot, control circuit 206 may temporarily abort the data acquisition atblock 1012 and return to block 1004 to restart vector signal analysisfor acquiring amplitude and timing data. The data acquisition may berestarted on a next processor interrupt signal or after a predeterminedtime interval, e.g., after one minute, five minutes or other selectedtime interval. In some examples, control circuit 206 may monitor theventricular cycle lengths and/or patient physical activity level untilthe abort condition is no longer detected and restart the dataacquisition at block 1004 when a relatively, stable ventricular rateand/or relatively low, stable patient physical activity is detected. Instill other examples, when an abort condition is detected, controlcircuit 206 may wait a predetermined time interval, e.g., one minute,and then resume motion sensor signal data collection. In some cases,data acquired before the abort condition was detected is discarded. Inother examples, data acquired before the abort condition was detected issaved and combined with data obtained after resuming data collection.

The data acquisition process may be restarted multiple times up to amaximum number of attempts or over a maximum time period, for examplefor up to one hour, four hours, 24 hours or other selected maximumattempt time period. If the maximum number of attempts or maximum timeperiod for successfully acquiring the amplitude and timing data for allvector signals being analyzed is expired at block 1010, the process maybe terminated at block 1020. The control circuit 206 may terminate anytemporary control parameters previously set to test values at block1002. For example, control circuit 206 may switch back to the programmedpacing mode, e.g., the VDD pacing mode, using any default or programmedatrial sensing control parameters at block 1024. Control circuit 206 maygenerate a notification at block 1022 indicating the automatic sensingparameter selection process was terminated. The notification generatedat block 1022 may include the number of data acquisition attempts orrestarts and/or the associated abort condition(s) detected. Anygenerated notifications may be transmitted by telemetry circuit 208 toexternal device 20 for display on display unit 54. A user may programatrial sensing control parameters for use during the VDD pacing mode.

When the data acquisition is completed, e.g., five minutes per testvector signal, within the maximum time period, control circuit 206advances to block 1014 to generate the data distributions, e.g., in theformat of histograms as generally shown in FIGS. 8, 10, 12 and 13. Basedon the histogram distributions, one or more atrial event sensingparameter values may be selected and set at block 1016. While detectionof an abort condition is indicated at block 1106, after acquiringamplitude and/or timing data from the motion sensor vector signals andbefore generating histogram distributions, it is to be understood thatan abort condition may be detected by control circuit 206 before,during, or after acquiring amplitude and timing data (block 1004),generating histogram distributions (block 1014) or selecting the A4sensing control parameters (block 1016). Monitoring for one or moreabort conditions, such as any of the examples described above, may beongoing during the process of blocks 1001 to 1016 and is not limited toa particular point in time during the process of setting testparameters, acquiring data, generating distributions of the data andselecting A4 sensing control parameters.

In some examples, the A4 sensing vector signal is selected at block 1016based on the histograms of the maximum vector signal amplitude duringthe A4 window generated for each vector signal. For each vector signalbeing analyzed, control circuit 206 may determine a valid maximumamplitude sample count. For example, the maximum amplitudes that aregreater than a minimum threshold amplitude, e.g., a minimum programmablevalue of the late atrial event sensing threshold amplitude, may becounted as valid maximum amplitude samples. Any vector signal having avalid maximum amplitude sample count that is less than a rejectionthreshold number of valid maximum amplitudes may be rejected as apossible A4 sensing vector signal. For instance, when less than 20 ofthe maximum amplitudes acquired for a given vector signal are determinedto be greater than the minimum programmable late atrial event sensingthreshold, the vector signal may be rejected from the selection processbecause the maximum amplitudes acquired for that vector signal meetrejection criteria.

Control circuit 206 may determine the median maximum amplitude out ofall maximum amplitudes acquired that are greater than the minimumprogrammable late atrial event sensing threshold value (or other minimumthreshold). The median maximum amplitude may be determined afterdiscarding maximum amplitudes less than a noise threshold for eachnon-rejected vector signal. For instance, for each vector signal notmeeting rejection criteria, the histogram bins that store the number ofmaximum amplitudes that are less than or equal to a minimum programmableA4 sensing threshold amplitude value may be discarded. A median of themaximum amplitudes may be determined from the distribution of maximumamplitudes in histogram bins greater than the minimum A4 sensingthreshold amplitude value. The vector signal corresponding to thehighest median maximum amplitude determined from the A4 windows may beselected as the A4 sensing vector signal at block 1016.

In the illustrative example given above of analyzing each of the fourvector signals designated by the accelerometer axis combinations of 1+2,1+3, 2+3 and 1+2+3, if all three of the two-axis signals have fewer thanthe threshold number of valid maximum amplitude sample points, thethree-axis vector signal may be selected as the A4 sensing vector signalat block 1016. When at least one of the three two-axis vector signalshas the requisite number of valid maximum amplitude sample points, thetwo-axis vector signal having the highest median maximum amplitude maybe selected as the A4 sensing vector signal (e.g., to conserve currentdrain required to power the third accelerometer axis). When two or moreof the two-axis vector signals have the same median maximum amplitudeduring the A4 window, a two-axis vector signal sharing the single axisused for determining patient physical activity may be selected. In otherexamples, the single-axis vector having the highest median maximumamplitude may be identified and any two-axis vector signal including thesingle-axis vector signal having the highest median maximum amplitudemay be selected. In one example, when axis 2 is generally aligned withthe longitudinal axis 108 of pacemaker 14 (see FIG. 2), priority isgiven to the 1+2 vector signal, then the 2+3 vector signal then the 1+3vector signal when the median maximum amplitude of the A4 window matchesbetween two or all three of the vector signals. The single-axis vectorsignal generally aligned with the longitudinal axis of the pacemaker 14may correspond to the highest A4 signal amplitude though this may varywith implant position and orientation. The single axis vector signalhaving the highest A4 signal amplitude may be identified from empiricaldata, and any two-axis vector signal including this identifiedsingle-axis vector may be given priority when two or more two-axisvector signals have equal median maximum amplitudes.

At block 1016, control circuit 206 may set the late A4 sensing thresholdamplitude value (applied during the A4 window during atrial trackingventricular pacing) based on the median value of the maximum amplitudesdetermined during the A4 window for the selected A4 sensing vectorsignal. In one example, the late A4 sensing threshold amplitude value isset to the median value of the maximum amplitudes determined during theA4 window for the selected A4 sensing vector signal. In other examples,the late A4 sensing threshold amplitude value is set to a percentage,e.g., 60 to 80% of the median maximum amplitude value. In some cases,the method of setting the late A4 sensing threshold amplitude valuedepends on the median maximum amplitude during the A4 window. Forexample, if the median maximum amplitude during the A4 window is 1.2m/s² (or other threshold acceleration), the late A4 sensing thresholdamplitude may be set to the median maximum amplitude. If the medianmaximum amplitude is greater than 1.2 m/s² (or other thresholdacceleration), the late A4 sensing threshold amplitude may be set to 70%of the median maximum amplitude of the A4 window, but not less than 1.2m/s² (or other minimum limit).

The method for setting the late A4 sensing threshold amplitude value maydiffer depending on the selected A4 sensing vector signal. For example,the late A4 sensing threshold amplitude may be set according to apercentage of the median or at least a minimum limit when a two-axisvector signal is selected as the A4 sensing vector signal. The late A4sensing threshold amplitude may be set according to a differentpercentage or limit when the three-axis vector signal is selected as theA4 sensing vector signal. The late A4 sensing threshold amplitude may beset within lower and upper limits, e.g., between 0.5 m/s² and 5.0 m/s².The minimum A4 sensing threshold amplitude may be different depending onthe number of accelerometer axis signals being combined in the selectedvector signal. For example, a relatively low minimum thresholdamplitude, e.g., 0.6 m/s², may be enforced for a single-axis vectorsignal; an intermediate minimum threshold amplitude, e.g., 0.7 m/s², maybe enforced for a two-axis vector signal, and the highest minimumthreshold amplitude, e.g., 0.8 m/s², may be enforced for a three-axisvector signal. A relatively higher minimum threshold amplitude settingmay be allowable for vector signals that are a combination of two or allthree accelerometer axis signals compared to single-axis vector signalsbecause with the addition of each axis signal additional noise isincluded in the summed axis signals.

Control circuit 206 may set an early A4 sensing threshold amplitude(applied during the A3 window during atrial tracking ventricular pacing)at block 1016. The early A4 sensing threshold amplitude may be set basedon the maximum amplitudes determined during the A3 window for theselected A4 sensing vector signal. In one example, the early A4 sensingthreshold amplitude value is set by determining the median maximumamplitude during the A3 window (for the selected A4 sensing vectorsignal), multiplying this median maximum amplitude by a multiplicationfactor, e.g., 1.5, and adding this product of the median maximumamplitude and the multiplication factor to the late A4 sensing thresholdamplitude. In some example, setting the early A4 sensing thresholdamplitude value may include adding an offset, e.g., by adding 0.3 m/s².The early A4 sensing threshold amplitude may be set based on the medianmaximum amplitude during the A4 window, the median maximum amplitudeduring the A3 window, or a combination of both which may be a weightedcombination. The early A4 sensing threshold amplitude may be set withinupper and lower limits, e.g., between 0.8 m/s² and 18.8 m/s² in oneinstance.

Control circuit 206 may set an A3 window ending time at block 1016 basedon the distribution of the timing of the latest test threshold crossingduring the A3 window determined for the selected A4 sensing vectorsignal. In one example, the A3 window ending time is set based on themedian time of the latest test threshold crossing during the A3 windowplus an offset, e.g., plus 50 to 150 ms. The A3 window ending time maybe set within minimum and maximum limits, e.g., not less than 650 ms andnot more than 1000 ms.

Upon completing the atrial event sensing control parameter selection atblock 1016, control circuit 206 may generate a notification at block1022 that parameter selection was complete, including selectedparameters. The selected parameters may be transmitted by telemetrycircuit 208 to external device 20 for generating a display of theresults of the automatic set-up procedure. Control circuit 206 mayswitch to the atrial tracking ventricular pacing mode, e.g., the VDDpacing mode, at block 1024 with the selected A4 sensing controlparameters in effect.

In some instances, the maximum amplitude during the A4 window may be toolow to reliably select A4 sensing control parameters. For example, whenfewer than a threshold number of sample points exceed the minimumprogrammable late A4 sensing threshold amplitude value for all vectorsignals, control circuit 206 may set the A4 sensing control parametersto default or previous settings and generate a notification indicating alow A4 signal amplitude at block 1022. The notification may betransmitted by pacemaker 14 and displayed by external device 20,allowing a user to select and program the pacing mode and sensingcontrol parameters.

It should be understood that, depending on the example, certain acts orevents of any of the methods described herein can be performed in adifferent sequence, may be added, merged, or left out altogether (e.g.,not all described acts or events are necessary for the practice of themethod). Moreover, in certain examples, acts or events may be performedconcurrently, e.g., through multi-threaded processing, interruptprocessing, or multiple processors, rather than sequentially. Inaddition, while certain aspects of this disclosure are described asbeing performed by a single circuit or unit for purposes of clarity, itshould be understood that the techniques of this disclosure may beperformed by a combination of units or circuits associated with, forexample, a medical device.

In one or more examples, the functions described may be implemented inhardware, software, firmware, or any combination thereof. If implementedin software, the functions may be stored as one or more instructions orcode on a computer-readable medium and executed by a hardware-basedprocessing unit. Computer-readable media may include computer-readablestorage media, which corresponds to a tangible medium such as datastorage media (e.g., RAM, ROM, EEPROM, flash memory, or any other mediumthat can be used to store desired program code in the form ofinstructions or data structures and that can be accessed by a computer).

Instructions may be executed by one or more processors, such as one ormore digital signal processors (DSPs), general purpose microprocessors,application specific integrated circuits (ASICs), field programmablelogic arrays (FPLAs), or other equivalent integrated or discrete logiccircuitry. Accordingly, the term “processor,” as used herein may referto any of the foregoing structure or any other structure suitable forimplementation of the techniques described herein. Also, the techniquescould be fully implemented in one or more circuits or logic elements.

Thus, a medical device has been presented in the foregoing descriptionwith reference to specific examples. It is to be understood that variousaspects disclosed herein may be combined in different combinations thanthe specific combinations presented in the accompanying drawings. It isappreciated that various modifications to the referenced examples may bemade without departing from the scope of the disclosure and thefollowing claims.

What is claimed is:
 1. A pacemaker comprising: a pulse generatorconfigured to generate pacing pulses; a sensing circuit comprising anR-wave detector for sensing R-waves from a cardiac electrical signal; amotion sensor comprising a plurality of axes, each axis of the pluralityof axes being configured to produce an axis signal; and a controlcircuit coupled to the motion sensor, the sensing circuit and the pulsegenerator and configured to: identify a plurality of ventricular events;following each of the plurality of ventricular events, set a sensingwindow; for each vector signal of a plurality of vector signals,determine a maximum amplitude of the vector signal during each of aplurality of the sensing windows, each of the plurality of vectorsignals comprising at least one axis signal from the motion sensor;select an atrial event sensing vector signal from among the plurality ofvector signals based on the determined maximum amplitudes; sense anatrial event from the selected atrial event sensing vector signal; andproduce an atrial sensed event signal in response to the sensed atrialevent.
 2. The pacemaker of claim 1, wherein the control circuit isfurther configured to: set a non-atrial tracking pacing mode prior toidentifying the plurality of ventricular events; determine the maximumamplitudes during the non-atrial tracking pacing mode; switch to anatrial tracking pacing mode after selecting the atrial event sensingvector signal; and sense the atrial event from the selected atrial eventsensing vector signal during the atrial tracking pacing mode.
 3. Thepacemaker of claim 1, wherein the control circuit is configured toselect the atrial event sensing vector signal by: determining a medianmaximum amplitude from the determined maximum amplitudes for at least aportion of the plurality of vector signals; and selecting the atrialevent sensing vector signal by selecting one of the plurality of vectorsignals having a highest median maximum amplitude.
 4. The pacemaker ofclaim 1, wherein the control circuit is configured to select the atrialevent sensing vector signal by: for each of the plurality of vectorsignals, determining a distribution of the determined maximumamplitudes; and selecting the atrial event sensing vector signal as oneof the plurality of vector signals having a non-normal distribution ofthe maximum amplitudes that is skewed right.
 5. The pacemaker of claim1, wherein the control circuit is configured to select the atrial eventsensing vector signal by selecting a vector signal of the plurality ofvector signals that is a combination of at least two of the axissignals.
 6. The pacemaker of claim 1, wherein the control circuit isconfigured to select the atrial event sensing vector signal by:determining, for each vector signal of the plurality of vector signals,a ratio of a first number of the maximum amplitudes greater than a highamplitude threshold to a second total number of the maximum amplitudes;and selecting the atrial event sensing vector signal as a vector signalof the plurality of vector signals having a highest value of the ratio.7. The pacemaker of claim 1, wherein the control circuit is furtherconfigured to: discard all maximum amplitudes that are less than a noisethreshold; and select the atrial event sensing vector signal from amongthe plurality of vector signals based on the determined maximumamplitudes after discarding the maximum amplitudes that are less thanthe noise threshold.
 8. The pacemaker of claim 1, wherein the controlcircuit is configured to select the atrial event sensing vector by:determining, for each of the plurality of vector signals comprising asingle axis signal, a ratio of a first number of the maximum amplitudesthat are greater than a high amplitude threshold to a second number ofthe maximum amplitudes that are greater than a noise threshold;comparing each of the determined ratios to a ratio threshold; inresponse to at least one ratio being greater than the ratio threshold,selecting the atrial event sensing vector as a single-axis vector signalhaving the ratio greater than the ratio threshold; and in response toall of the determined ratios being less than the ratio threshold,selecting the atrial event sensing vector signal as a combination of atleast two of the axis signals.
 9. The pacemaker of claim 1, wherein: thepacemaker comprises a housing having a longitudinal axis and enclosingthe motion sensor and the control circuit; the motion sensor comprisinga first axis configured to produce a longitudinal axis signal, the firstaxis aligned with the longitudinal axis of the pacemaker housing; andthe control circuit is configured to select the atrial event sensingvector signal as a combination at least two axis signals produced by twodifferent axes of the motion sensor, the at least two axis signalscomprising the longitudinal vector signal.
 10. The pacemaker of claim 1,further comprising a telemetry circuit, wherein the control circuit isconfigured to: determine that the determined maximum amplitudes of eachvector signal of the plurality of vector signals meet rejectioncriteria; generate an alert in response to determining that therejection criteria are met for each vector signal of the plurality ofvector signals, and control the telemetry circuit to transmit the alertto an external medical device.
 11. The pacemaker of claim 1, wherein thecontrol circuit is further configured to, for each vector signal of theplurality of vector signals: determine a count of the determined maximumamplitudes that are greater than a minimum threshold; compare the countof maximum amplitudes greater than the minimum threshold to a rejectionthreshold; and reject the vector signal in response to the count beingless than the rejection threshold.
 12. The pacemaker of claim 11,wherein the control circuit is further configured to: for each vectorsignal of the plurality of vector signals that is not rejected,determine a median maximum amplitude from the maximum amplitudes thatare greater than the minimum threshold; and select the atrial eventsensing vector signal as a vector signal of the plurality of vectorsignals that is not rejected and has a highest median maximum amplitude.13. The pacemaker of claim 11, wherein the control circuit is furtherconfigured to: determine that each vector signal of the plurality ofvector signals that comprises a combination of two of the axis signalsis a rejected vector signal; and select the atrial event sensing vectorsignal as a vector signal of the plurality of vector signals that is acombination of at least three axis signals.
 14. The pacemaker of claim1, wherein the control circuit is further configured to: determine aplurality of ventricular cycle lengths; set a passive ventricularfilling window ending time based on the plurality of ventricular cyclelengths; and set the sensing window to start at the passive ventricularfilling window ending time.
 15. The pacemaker of claim 1, wherein: thecontrol circuit is configured to start an atrioventricular pacinginterval in response to the atrial sensed event signal; and the pulsegenerator generates a ventricular pacing pulse in response to theatrioventricular pacing interval expiring.
 16. A method, comprising:producing an axis signal from each axis of a plurality of axes of amotion sensor; identifying a plurality of ventricular events; followingeach of the plurality of ventricular events, setting a sensing window;for each vector signal of a plurality of vector signals, determining amaximum amplitude of the vector signal during each of a plurality of thesensing windows, where each vector signal of the plurality of vectorsignals comprises at least one axis signal from the motion sensor;selecting an atrial event sensing vector signal from the plurality ofvector signals based on the determined maximum amplitudes; sensing anatrial event from the selected atrial event sensing vector signal; andproducing an atrial sensed event signal in response to sensing theatrial event.
 17. The method of claim 16, further comprising: setting anon-atrial tracking pacing mode prior to identifying the plurality ofventricular electrical events; determining the maximum amplitudes duringthe non-atrial tracking pacing mode; switching to an atrial trackingpacing mode after selecting the atrial event sensing vector signal; andsensing the atrial event from the selected atrial event sensing vectorsignal during the atrial tracking pacing mode.
 18. The method of claim16, further comprising selecting the atrial event sensing vector signalby: determining a median maximum amplitude from the determined maximumamplitudes for at least a portion of the plurality of vector signals;and selecting the atrial event sensing vector signal by selecting one ofthe plurality of vector signals having a highest median maximumamplitude.
 19. The method of claim 16, further comprising: for eachvector signal of the plurality of vector signals, determining adistribution of the determined maximum amplitudes; and selecting theatrial event sensing vector signal by selecting at least one of theplurality of vector signals having a non-normal distribution of themaximum amplitudes that is skewed right.
 20. The method of claim 16,wherein selecting the atrial event sensing vector signal comprisesselecting a vector signal of the plurality of vector signals that is acombination of at least two of the axis signals.
 21. The method of claim16, wherein selecting the atrial event sensing vector signal comprises:determining for each vector signal of the plurality of vector signals aratio of a first number of the maximum amplitudes greater than a highamplitude threshold to a second total number of the maximum amplitudes;and selecting the atrial event sensing vector signal as a vector signalof the plurality of vector signals having a highest value of the ratio.22. The method of claim 16, further comprising discarding all maximumamplitudes that are less than a noise threshold; and select the atrialevent sensing vector signal from among the plurality of vector signalsbased on the determined maximum amplitudes after discarding the maximumamplitudes less than the noise threshold.
 23. The method of claim 16,wherein selecting the atrial event sensing vector comprises:determining, for each of the plurality of vector signals comprising asingle axis signal, a ratio of a first number of maximum amplitudesgreater than a high amplitude threshold to a second number of maximumamplitudes greater than a noise threshold; comparing each of thedetermined to a single-axis vector threshold; in response to at leastone ratio being greater than the single-axis vector threshold, selectingthe atrial event sensing vector signal as a single-axis vector signalhaving a ratio greater than the single-axis vector threshold; and inresponse to all of the determined ratios being less than the single-axisvector threshold, selecting the atrial event sensing vector signal as acombination of at least two axis signals.
 24. The method of claim 16,wherein selecting the atrial event sensing vector signal comprisesselecting a combination at least two axis signals produced by twodifferent axes of the motion sensor, the at least two axis signalscomprising a longitudinal axis signal produced by a motion sensor axisaligned with a longitudinal axis of a housing of a medical device thatencloses the motion sensor.
 25. The method of claim 16, furthercomprising: determining that the determined maximum amplitudes of eachvector signal of the plurality of vector signals meet rejectioncriteria; generating an alert in response to determining that therejection criteria are met for each vector signal of the plurality ofvector signals, and transmitting the alert.
 26. The method of claim 16,further comprising, for each vector signal of the plurality of vectorsignals: determining a count of the determined maximum amplitudes thatare greater than a minimum threshold; comparing the count of maximumamplitudes greater than the minimum threshold to a rejection threshold;and rejecting the vector signal in response to the count being less thanthe rejection threshold.
 27. The method of claim 26, wherein the controlcircuit is further configured to: for each vector signal of theplurality of vector signals that is not rejected, determining a medianmaximum amplitude from the maximum amplitudes that are greater than theminimum threshold; and selecting the atrial event sensing vector signalas a vector signal of the plurality of vector signals that is notrejected and has a highest median maximum amplitude.
 28. The method ofclaim 26, further comprising: determining that each vector signal of theplurality of vector signals that comprises a combination of two of theaxis signals is a rejected vector signal; and selecting the atrial eventsensing vector signal as a vector signal of the plurality of vectorsignals that is a combination of at least three axis signals.
 29. Themethod of claim 16, further comprising: determining a plurality ofventricular cycle lengths; setting a passive ventricular filling windowending time based on the plurality of ventricular cycle lengths; andsetting the sensing window to start at the passive ventricular fillingwindow ending time.
 30. The method of claim 16, further comprising:starting an atrioventricular pacing interval in response to the atrialsensed event signal; and generating a ventricular pacing pulse inresponse to the atrioventricular pacing interval expiring.
 31. Anon-transitory, computer-readable storage medium comprising a set ofinstructions which, when executed by a control circuit of a pacemaker,cause the pacemaker to: produce an axis signal from each axis of aplurality of axes of a motion sensor; identify a plurality ofventricular events; following each of the plurality of ventricularevents, set a sensing window; for each vector signal of a plurality ofvector signals, determine a maximum amplitude of the vector signalduring each of a plurality of the sensing windows, where each vectorsignal of the plurality of vector signals comprises at least one axissignal from the motion sensor; select an atrial event sensing vectorsignal from the plurality of vector signals based on the determinedmaximum amplitudes; sense an atrial event from the selected atrial eventsensing vector signal; and produce an atrial sensed event signal inresponse to sensing the atrial event.